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

 
We decided that the Plan does not have to pay for procedure codes 85007 and 85008 billed for date of service 
July 27, 2023. 
 
You asked the Plan to pay for procedure codes 85007 and 85008. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these codes are not 
payable as they were billed with code 85027. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that a laboratory shall not report CPT codes 85007 or 85008 with codes 85025 or 85027.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 85007 and 85008 have not been met. Specifically, these two codes were 
inappropriately reported with code 85025, which the Plan has agreed to pay for. It is not appropriate to bill 
codes 85007 and 85008 with code 85025, as these services are automatically included in procedure code 
85025. Therefore, we decided that the Plan does not have to pay for procedure codes 85007 and 85008 billed 
for date of service July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 22, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that this was an annual eye examination and prior 
authorization should not be required. The Plan denied your request. The Plan says the provider was out-of-
network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on October 22, 2022, by an out-of-
network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 home health skilled nursing visits.  

You asked the Plan to pre-approve 7 home health skilled nursing visits. You say that you would like to request 
reconsideration of the denied home health services and that the services requested are medically necessary. The 
Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee's 
condition has not significantly changed. They continue to require supplemental oxygen and BiPAP for 
assistance and has been educated regarding her congestive heart failure. They have not been recently 
hospitalized. The patient refused foot care at their last skilled nursing care visit, and they are not noted to 
require wound care or complex foot care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 7 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on May 10, 2023, to, June 
9, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that you have had severe foot pain for many 
years now and have been treated by several doctors, but no one has been able to relieve the pain. You say that 
you were told that you would only have to pay a $15 copayment. The Plan denied your request. The Plan says 
that acupuncture benefit is not covered when solely provided by an independent acupuncturist. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pay for the acupuncture services provided on May 10, 2023, to, June 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services described by code 82947 performed 
on date of service May 10, 2023. 
 
You asked the Plan to pay for 82947. You say that 82947 should be paid as billed because it is supported in the 
documentation and enrollee was seen for these services by a provider under the same billing group as their 
primary care provider. The Plan denied your request. The Plan says 82947 is denied because it is not a FQHC 
benefit. 
 
The Plan follows Medicare rules. Medicare rules say that RHCs and FQHCs are institutional claims submitted 
on TOB 71x and 77x. The rules also say that laboratory services are not within the scope of the RHC or FQHC 
benefit. 
 
We looked at the file and Medicare rules. In this case, we confirmed that 82947 is a laboratory service. We 
confirmed that 82947 was billed on TOB 771, which indicates it is a FQHC claim. FQHCs only bill services 
that are part of the FQHC benefit on the TOB 77X claim. Per Medicare rules, laboratory services, like code 
82947, are not within the scope of the FQHC benefit. Therefore, the claim for code 82947 billed on TOB 771 
was correctly denied. Based on this information, we decided that Medicare rules for coverage of 82947 have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services described by 
code 82947 performed on date of service May 10, 2023.
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 96374 and 96375. We decided that the Plan does not 
have to pay for procedure codes 74177, 93005, and 96376.  
 
You asked the Plan to pay for the outpatient hospital care billed for date of service December 6, 2022. You say 
that the codes are not bundled items. The Plan says that the services are not separately payable. 
 
We decided that the Plan has to pay for procedure codes 96374 and 96375.  
 
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 codes 96374 and 96375 have a status indicator of S. These services are separately payable unless 
they are billed with a J1 status indicator. The case file does not show that a code with a J1 status indictor was 
billed on the claim at issue. Therefore, we decided that the Plan has to pay for procedure codes 96374 and 
96375 billed for date of service December 6, 2022.  
 
We also decided that the Plan does not have to pay for procedure codes 74177, 93005, and 96376. 
 
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 code 74177 has a Q3 status indicator. When HCPCS codes that meet the criteria for payment of 
the composite APC are billed on the same date of service, CMS makes a single payment for all of the codes as 
a whole, rather than paying individually for each code. 
 
We find that code 93005 has a Q1 status indicator. Separate payment is made only if there is no service with 
status indicator S, T, or V reported on the same claim. In this case, code 93005 was billed on the same claim as 
a service with a status indicator of S.  
 
We find that code 96376 has a N status indicator. Payment for services with a status indicator N is packaged 
into payment for a separately paid service.  
 
We looked at the file and the rules. Based on this information, we decided that the Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 74177, 93005, 
and 96376 billed for date of service December 6, 2022. 
 
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 procedure code 81345 billed for date of service May 23, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 81345 is bundled into payment for 
code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 code 81345 billed for date of service May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87150 and 87801) billed for date of 
service August 12, 2022. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this panel was not billed in accordance with 
Medicare guidelines. 
 
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 was a test panel. 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 laboratory panel (87150 and 87801) billed for date of service August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve VIA Disc allograft intervertebral disc augmentation 
procedure. 
 
You asked the Plan to pre-approve VIA Disc allograft intervertebral disc augmentation procedure. You say that 
you are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says it 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 VIA Disc allograft intervertebral disc 
augmentation procedure. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, 
long-term peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with 
conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested VIA disc allograft 
intervertebral disc augmentation procedure is not medically reasonable or 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 VIA Disc allograft intervertebral disc augmentation procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve VIA Disc allograft intervertebral disc 
augmentation procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Breast Cancer 1 and 2 (BRCA1/2) panel (81433) 
provided July 27, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that the enrollee's physician ordered genetic testing 
due to its validated clinical utility in clarifying disease risk.  The Plan denied your request. The Plan says the 
requested genes for this test are already included in the approved test (81432) and is not covered by Medicare. 
 
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 81433 is hereditary breast cancer-related disorders (eg, 
hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion 
analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11. 
 
We find that CPT code 81433 is not supported in the medical record. Specifically, the requested genes for the 
Invitae BRCA1/2 Panel (81433) are already included in the Invitae Breast Cancer panel (81432) which is 
duplicative and is not expected to give additional information separate from the approved test. Also, per DEX 
diagnostics the Invitae BRCA1/2 panel is not covered by Medicare. 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 Invitae Breast Cancer 1 and 2 (BRCA1/2) panel (81433) provided July 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has tried mirabegron in both pill 
and liquid form without relief of overactive bladder symptoms. You also say the enrollee has been using 
Gemtesa with relief of symptoms since May of 2021. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) provided on July 
31, 2023. 
 
You asked the Plan to pay for the cone beam CT scan. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pay for a cone 
beam computed tomography (CT) provided on July 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 19, 2023, by an out-
of-network OON provider.  
 
You asked the Plan to pay for the lab services. 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 laboratory services provided on May 19, 2023, 
by an out-of-network OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on September 11, 2023, and billed with codes 87500, 87591, 87481, 87651, 87653, 87641, 87798, 
87491, 87496, 87529, 87532, and 87563. 
 
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 testing provided on September 
11, 2023, and billed with codes 87500, 87591, 87481, 87651, 87653, 87641, 87798, 87491, 87496, 87529, 
87532, and 87563.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on June 12, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process.  
 
We looked at the file and Medicare rules. The DEX database shows that PrismRA is not covered. Based on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. Therefore, 
we decided that the Plan does not have to pay for the PrismRA test (81479) provided on June 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0157, G0299, G5001) 
provided from May 17, 2023, to May 25, 2023. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as 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 May 17, 2023. The NOA was not received by the Plan until June 20, 2023. 
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 home health services (G0151, G0157, 
G0299, G5001) provided from May 17, 2023, to May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a retainer crown - full cast high noble metal (D6790) 
provided on June 13, 2023. 
 
You asked the Plan to pay more for the retainer crown. You say that they are charging you $259.30 for services 
provided on June 13, 2023 and they did a pre-authorization and stated you would have to pay $89. You also say 
that you paid $89 on this date of service and you made it clear that you did not want anything done that your 
insurance would not cover The Plan denied your request. The Plan says your benefit for the requested service 
$3,500 dollar limit was met. 
 
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, certain limitations apply. The record 
shows your benefit for the requested service has been exhausted. The Plan has provided evidence having made 
payments totaling $3,500 towards the cost of the dental services provided on June 13, 2023. This included a 
partial payment of $568 towards the crown in dispute. The Plan also provided evidence of the dental providers 
submitted ledger that shows that you were charged $85 for SLT -Subgingival Laser Troughing. This dental 
service was not billed on the claim nor is there another $89 charge billed to the plan for this date of service. 
Therefore, we decided that the Plan does not have to pay more for a retainer crown - full cast high noble metal 
(D6790) provided on June 13, 2023.