Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81209 and 81223 billed for date of service 
February 21, 2023. 
 
You asked the Plan to pay for procedure codes 81209 and 81223. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the provided records do not support the services 
billed. 
 
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 81209 is: BLM (Bloom syndrome, RecQ helicase-like) 
(eg, Bloom syndrome) gene analysis, 2281del6ins7 variant. 
 
The definition of code 81223 is: CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 81209 and 81223. Our reviewer says that 
procedure codes 81209 and 81223 do not meet criteria for payment. Our reviewer found that the medical record 
supports that a saliva specimen was tested and attested by the ordering physician; however, a physician order 
for these tests was not found in the medical record. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 81209 and 81223 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 81209 and 81223 billed for date of service February 21, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2751) provided on June 29, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges, and they would cause financial hardship. The Plan denied your request. The Plan 
says the cost-sharing applied correctly based on the services provided. 
 
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. 
 
You have been asked to pay a 50% coinsurance for a crown. This item/service falls within the Class 3 Major 
Dental Services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to pay more for a crown (D2751) provided on June 29, 
2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 rendered on August 17, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that G0483 was not billed with an NCCI-allowed modifier. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the plan has not submitted a valid denial in this case. Medicare has 
clarified that the edit between 80307 and G0483 is invalid. Medicare has confirmed that these codes can and 
should be paid together. Therefore, we decided that the Plan has to pay for procedure code G0483 rendered on 
August 17, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a breast cancer panel (procedure code 81432 and 81433) 
rendered on June 17, 2023. 
 
You asked the Plan to pay for the services. You say that the results of this test directly impact clinical decision 
making and guide both the physician and patient in medical management. The Plan denied your request. The 
Plan says this request represents apparent claim unbundling and is not allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81432 and 81433 are not supported in the medical record. Specifically, one code should 
be used to report these services. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for a breast cancer panel 
(procedure code 81432 and 81433) rendered on June 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies for a continuous positive airway pressure (CPAP) 
device. 
 
You asked the Plan to pay for CPAP supplies. You say that you have reported and documented the items at 
issue correctly. The Plan denied your request. The Plan says the documentation requirements have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid proof of delivery for the supplies provided on the date of service at issue in 
this case. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for supplies for a continuous positive airway 
pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 28, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291 and 33620 billed for date of service 
July 26, 2023. 
 You asked the Plan to pay for procedure codes 99291 and 33620. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 99291 is bundled into payment for code 
33620. Code 33620 is 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, we have confirmed that code 99291 
is a column II code to column I code 33620. This claim has not been billed with an appropriate modifier to 
bypass the edit. Code 33620 is not supported as the medical records submitted indicate that this procedure was 
provided on a different date of service. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99291 and 33620 billed for 
date of service July 26, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT procedure. 
 
You asked the Plan to pre-approve the SPRINT procedure. You say that the SPRINT procedure is 
medically necessary. The Plan denied your request. The Plan says the SPRINT procedure is not medically 
necessary. 
 
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 the SPRINT procedure. Our reviewer 
says that the requested SPRINT procedure is not considered medically reasonable and necessary. Our 
physician reviewer found this is considered experimental/investigational for the treatment of low back 
pain/lumbar radiculopathy. Therefore, the request is deemed not medically reasonable and necessary. 
 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 SPRINT procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve manual wheelchair and additional parts. 
 
You asked the Plan to pre-approve manual wheelchair and additional parts. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says Medicare does not cover Durable Medical 
Equipment in a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that manual wheelchair and additional parts is being requested for use in a SNF. Therefore, we 
decided that the Plan does not have to pre-approve manual wheelchair and additional parts.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 11, 2022, billed with 
procedure code 64450-XU. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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, we have confirmed that code 64450-XU is a column II code to column I code 01402; however, 
64450-XU was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical record describes regional 
block was given during anesthesia services. Anesthesia start time 11:39 and stop time 1407. Regional block 
was performed at 1220.  Per 2023 NCCI Chapter II a peripheral nerve block injection (CPT) codes 64XXX for 
postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the mode 
of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection, and the 
adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block injection. An epidural 
or peripheral nerve block injection (code numbers as identified above) administered preoperatively or 
intraoperatively is not separately reportable for postoperative pain management if the mode of anesthesia for 
the procedure is monitored anesthesia care, moderate conscious sedation, regional anesthesia by peripheral 
nerve block, or other type of anesthesia not identified above. In this case, service was unbundled.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 11, 2022, billed with procedure code 
64450-XU.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 30, 2023, billed with 
procedure code 64447-59. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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, we have confirmed that code 64447-59 is a column II code to column I code 01402; however, 
64447-59 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the medical record does not include 
sufficient documentation to confirm surgeon requested injection for post operative pain management, as well as 
a procedure report to support anesthesia service was not dependent on injection. Therefore, this procedure 
cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on May 30, 2023, billed with procedure code 
64447-59.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 23, 2022, to 
September 15, 2022. 
 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 23, 2023. The NOA was not received by the Plan until December 
10, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from August 23, 2022, to September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) provided January 30, 
2023. 
 You asked the Plan to pay for the laboratory testing. You say that the DecisionDx-SCC test is a covered 
Medicare benefit and should be a covered benefit for the enrollee. The Plan denied your request. The Plan says 
this test is not covered at this time. 
 
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. The DEX Diagnostics Exchange Registry documents the 
DecisionDx-SCC testing has been evaluated by the MolDX Program and is considered non-covered at this 
time. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC testing (0315U) 
provided January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87798, 87640, 87653, 87481, 87641) provided 
on August 1, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
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 lab services (87798, 87640, 87653, 87481, 87641) provided on August 1, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
August 02, 2023. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was supposed to be 
a screening. No one told you that you had any biopsys done. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 
copayment for outpatient surgery. 
 
You have been asked to pay a $290 copayment for a diagnostic colonoscopy. This item/service falls within the 
outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic 
colonoscopy provided on August 02, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT scan) of the thorax and 
hospital outpatient clinic visit billed with codes 71250 and G0463 provided on May 1, 2023. 
 
You asked the Plan to pay for the CT scan and outpatient visit. You say that the services were billed correctly 
and should be paid. The Plan denied your request. The Plan says that codes with OPPS status indicators of S 
and V cannot be billed on the same date without modifier -25. CPT code 71250 has an OPPS status indicator 
S and G0463 has an OPPS status indicator V. Therefore, codes 71250 and G0463 are not payable.  
 
The Plan must follow Medicare rules. Medicare rules say that when modifier 25 is reported with an Evaluation 
and Management (E&M) code, or a code that is assigned a status indicator V, it is identifying that the service 
reported is a medical visit that takes place on the same date that a procedure code with status indicator S or T is 
performed, but that is significant and separately identifiable from the procedure. 
 
We looked at the file and Medicare rules. In this case, code 71250 has an OPPS status indicator of S. It was 
billed on the same date as code G0463, with a status indicator of V, but code G0463 was not billed with 
modifier -25 as required. Based on this information, we decided that Medicare rules for coverage of the CT 
scan and outpatient visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT scan) of the thorax and hospital outpatient clinic visit billed with codes 71250 and 
G0463 provided on May 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme Next Generation Sequencing 
(NGS) panel provided on July 1, 2023. 
 
You asked the Plan to pay for the FoundationOne Heme testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing is not covered because the enrollee has no 
planned treatment, and this test is not on the FDA list. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. In this case we do not find that the requested test has FDA approval 
or clearance as a companion in vitro diagnostic. Additionally, it does not appear that the enrollee had decided 
to seek further cancer treatment. Based on this information, we decided that Medicare rules for coverage of the 
FoundationOne Heme testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the FoundationOne Heme Next Generation Sequencing (NGS) panel provided on July 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care services provided on 
August 14, 2023. 
 
You asked the Plan to waive the copayment for the urgent care services. You say that you do not feel you 
should have to pay the copay as you were told by the office staff that the copay would not apply. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 
copayment for urgently needed services. 
 
You have been asked to pay a $60 copayment for the urgent care services. This item/service falls within the 
urgently needed services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the urgent 
care services provided on August 14, 2023.