Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim partial denture (D5820). 
 
You asked the Plan to pre-approve interim partial denture. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this service is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
interim partial denture (D5820).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ImpediMed L-Dex testing device (93702). 
 
You asked the Plan to pre-approve the ImpediMed L-Dex testing device. You say that you believe the use of 
ImpediMeds L-Dex device is medically necessary. The Plan denied your request. The Plan says this device is 
considered investigational and there is insufficient evidence in its safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Per the Plan's Medical Policy #261, Bioimpedance devices for the 
detection of lymphedema, this is considered investigational. Based on this information, we decided that 
Medicare rules for coverage of the ImpediMed L-Dex testing device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the ImpediMed L-Dex testing device (93702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
September 18, 2023, and billed with codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 87529, 87532, 
87563, 87591, 87661, 87481, 87651, and 87653. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says per Local Coverage Article (LCA) A58726, this type of testing must be 
billed as a single unit of service with a single code. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on September 18, 
2023, and billed with codes 87500, 87641, 87798, G0452, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 
87661, 87481, 87651, and 87653.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with code 29999 for April 19, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is no documentation to support that the services were 
necessary for the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services 
billed with code 29999 for April 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 9, 2022, 
through March 23, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
inpatient hospital services should be paid at the DRG originally billed because the recoupment by the Plan 
results in an underpayment for the services rendered. The Plan denied your request. The Plan says no medical 
records were received; therefore, it was not possible to confirm the DRG as originally billed. As such, the claim 
was adjusted to a DRG that is arguably supported because this outcome is more beneficial to all stakeholders 
than denying the claim entirely. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules also say that providers must report services correctly. Providers must 
report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal 
and secondary diagnosis codes. 
 
We looked at the file and Medicare rules. We confirmed that in this case, no medical records were received. 
The case file contains evidence that the Plan requested these records on multiple occasions. Without records, 
we are unable to determine if the DRG as originally billed is supported or not. Based on this information, we 
decided that there is insufficient information in the record to determine if Medicare rules for coverage of the 
inpatient hospital services at the DRG originally billed have been met. Therefore, we decided that the Plan does 
not have to pay for inpatient hospital services provided on March 9, 2022, through March 23, 2022, at the 
Diagnosis Related Group (DRG) originally billed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97530, 97110, 97112, 97116, and 97535 
billed for August 2, 2023, to August 31, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 97530, 97110, 97112, 97116, and 97535 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. The definition 
of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop 
strength and endurance, range of motion and flexibility. The definition of code 97112 is therapeutic procedure, 
1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic 
sense, posture, and/or proprioception for sitting and/or standing activities. The definition of code 97116 is 
therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing). The definition 
of code 97535 is self-care/home management training (eg, activities of daily living (ADL) and compensatory 
training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive 
equipment) direct one-on-one contact, each 15 minutes. 
 
We find that CPT codes 97530, 97110, 97112, 97116, and 97535 are not supported in the medical record. 
Specifically, there is no documentation of the total time spent performing each activity. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 97530, 97110, 97112, 97116, and 97535 billed 
for August 2, 2023, to August 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (81291) provided July 17, 2023.  

You asked the Plan to pay for the genetic testing. You say that the claim was rejected due to missing medical 
records/documents. Please find the requested documents attached The Plan denied your request. The Plan says 
genetic testing procedures submitted under CPT code 81291 are non-covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. CPT code 81291 is listed in Local Coverage Article A56199 under 
Group 3, Tier 1 non-covered codes. Based on this information, we decided that Medicare rules for coverage of 
the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing (81291) provided July 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 13, 2023, billed with 
codes 81231, 81232, 81306 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 13, 2023, billed with codes 81231, 81232, 81306 and 81335.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation (0055T). 
 
You asked the Plan to pre-approve computer-assisted surgical navigation. You say that the requested service is 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve computer-assisted surgical navigation. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that no large-volume, long-term/high-quality clinical studies confirm the clinical benefits (ultimate outcomes of functional improvement and pain reduction) of computer-assisted surgery over 
standard surgical approaches in total-knee arthroplasty. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted surgical navigation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computer-assisted surgical navigation (0055T).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 80307 billed for date of service July 10, 
2023.  
 
You asked the Plan to pay for procedure code 80307. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 80307 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 80307 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 80307 billed for date of service July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Nalu peripheral nerve stimulator (PNS) 
device (64555). 
 
You asked the Plan to pre-approve a Nalu PNS. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that an electro-acupuncture device is non-covered by 
Medicare when used for acupuncture (stimulation of auricular acupuncture points) for any indication. Based on 
this information, we decided that Medicare rules for coverage of a Nalu PNS have not been met. Therefore, we 
decided that the Plan does not have to pre-approve placement of a Nalu peripheral nerve stimulator (PNS) 
device (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 
You asked the Plan to pre-approve the requested ILR procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found that the enrollee would not benefit from an ILR. In the absence of any 
symptoms, recent unexplained syncope or cryptogenic cerebral vascular accident (CVA)/transient ischemic 
attack (TIA), placement of an ILR is not helpful or indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 21, 2023, billed with 
codes 81227, 81240, 81241 and 81291. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 21, 2023, billed with codes 81227, 81240, 81241 and 81291.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Insertion of a central venous tube provided on September 
07, 2023. 
 
You asked the Plan to pay for the Insertion of a central venous tube. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the Insertion of a central venous tube provided on September 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit and debridement provided on May 31, 2023. 
 
You asked the Plan to pay for a home visit and debridement. You say that you realize the services were 
rendered by an out-of-network provider, but you knew nothing about a prior authorization. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for a home visit and debridement provided on May 31, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation provided on August 1, 
2023, by an OON provider.  
 
You asked the Plan to pay for the interrogation device evaluation. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
the interrogation device evaluation provided on August 1, 2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 26, 2023, billed with 
codes 87481, 87491, 87496, 87511, 87529, 87563, 87591, 87640, 87641, 87651, 87653, 87661, 87556 and 
87798. 
 
You asked the Plan to pay for laboratory services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided on June 26, 2023, billed with codes 87481, 87491, 
87496, 87511, 87529, 87563, 87591, 87640, 87641, 87651, 87653, 87661, 87556 and 87798.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on October 16, 2023. 
 
You asked the Plan to pay for the wound care supplies. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that 
would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to 
pay for the wound care supplies provided on October 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
August 16, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239) provided on August 16, 2023.