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

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, 88377, and 88381 
billed for date of service February 8, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, 88360, 88377, and 88381. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, 
88377, and 88381. This means there is both a professional and technical component for the CPT codes. In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
88341, 88342, 88360, 88377, and 88381. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341, 88342, 88360, 88377, and 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 88341, 88342, 88360, 88377, and 88381 billed for date 
of service February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87086 billed for date of service June 23, 
2022. 
 
You asked the Plan to pay for procedure code 87086. You say that this service was medically necessary and 
appropriate. The Plan denied your request. The Plan says the diagnosis billed on this claim does not support the 
medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 87086. Codes which are not included in the coding manual list are considered not 
medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 87086 have not been met. Specifically, the diagnosis code(s) billed on this claim 
are not included on the list of appropriate codes to support the medical necessity of procedure code 87086. 
Therefore, we decided that the Plan does not have to pay for procedure code 87086 billed for date of service 
June 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on July 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for the subsequent hospital care rendered on July 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 20, 2021, to April 29, 2021. 
 
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 the provider did not bill as required by Medicare coding regulations. 
 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
provider did not send in a valid 5-day MDS assessment set in the right time period for this. This documentation 
is necessary to verify if the services were reported correctly.. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided to the enrollee from April 20, 2021, to April 29, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a specialist office visit provided on June 29, 2022, by an OON 
provider. 
 
You asked the Plan to pay for a specialist office visit. You say that the enrollee should not need authorization 
for an office visit. The Plan denied your request. The Plan says that payment is denied for absence of 
precertification/authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that that non-contracted providers, also known as out-of-network providers (OON), are not required 
to obtain prior authorization for services. 
 
The requested provider in this case is not a network provider with the Plan. The contract with the Plan clearly 
states that out-of-network providers are not required to obtain prior authorization for services. Therefore, we 
decided that the Plan has to pay for a specialist office visit provided on June 29, 2022, by an OON provider.  
 
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 lab services provided on March 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 18, 2022, 
through March 19, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. There is an NOA 
submitted with the "from" date as January 19, 2022, representing the continued care in 2022. However, the 
claim for the 30-day period of care, i.e., from February 18, 2022, through March 19, 2022, is submitted 
incorrectly with the admit date as December 20, 2021. Per Medicare guidelines, required NOA document in 
order to process final. we find the Medicare rule for payment of this February 18, 2022, through March 19, 
2022, claim has not been met and could not be processed for payment. Therefore, we decided that the Plan does 
not have to pay for the home health services provided from February 18, 2022, through March 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88381 billed for date of service February 
1, 2022. 
 You asked the Plan to pay for procedure code(s) 88381. You say that you disagree with the denial. The Plan 
denied your request. The Plan says this code is included in the skilled nursing facility payment and is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 88381 has a Professional/Technical indicator of 1. This means that CPT code 88381 has 
both a professional and technical component. In this case, CPT code 88381 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 88381 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code(s) 88381 billed for date of service February 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service June 23, 
2021. 
 
You asked the Plan to pay for procedure code 88377. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 88377 is bundled into payment for code 88325. 
 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 88377 
is a column II code to column I code 88325. 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 88377 billed for date of service June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliances 
provided on April 20, 2022. 
 
You asked the Plan to pay for the segmental gradient pressure pneumatic appliances. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT code E0673 is not supported in the medical record. Specifically, this item was provided in 
the ambulatory surgical center place of service. Durable medical equipment should be billed with a location 
where the enrollee will primarily use the item. This item is not separately payable in the ambulatory surgical 
center setting. Based on this information, we decided that Medicare rules for coverage of the segmental 
gradient pressure pneumatic appliances have not been met. Therefore, we decided that the Plan does not have 
to pay for the segmental gradient pressure pneumatic appliances provided on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85025, 85014, 85018, 85049) provided on 
August 10, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the corrected claim was not filed in a timely fashion. 
 
The Plan must follow Medicare rules. Medicare rules say that a corrected claim must be submitted within 1 
year from the date of the initial determination or re-determination. 
 
We looked at the file and Medicare rules. The original claim was processed on August 19, 2020. The corrected 
claim was not received until June 15, 2022. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services (85025, 85014, 85018, 85049) provided on August 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 19, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the records support multiple procedures for 
this date of service. 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 76641 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 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service August 19, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body 
(78816). 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that based on the additional information available, this request does not meet the 
Medicare or health plan criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found that per the guidelines, 
this scan may be covered for initial staging for malignant neoplasm for Stage III or higher. The enrollee has 
been classified as pT3a. Thus, according to the guidelines, the enrollee would qualify for this PET/CT scan. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation 
correction and anatomical localization imaging; whole body (78816).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services (procedure code 99356) provided to the 
enrollee on April 20, 2022. 
 
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 the add-on code was submitted without the primary procedure 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 99356 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for inpatient services (procedure code 99356) provided to the enrollee on April 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Continuous intraoperative neurophysiology monitoring 
(IONM), from outside the operating room (G0453) provided on December 2, 2021. 
 
You asked the Plan to pay for the Continuous intraoperative neurophysiology monitoring, from outside the 
operating room (G0453). You say that the Continuous intraoperative neurophysiology monitoring, from outside 
the operating room (G0453) is medically necessary. The Plan denied your request. The Plan says they were 
unable to make a determination within the allotted time frame. 
 
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 pay for the Continuous intraoperative neurophysiology monitoring, from outside the operating room (G0453). Our reviewer says that the Continuous 
intraoperative neurophysiology monitoring, from outside the operating room (G0453) is not medically 
necessary. Our physician reviewer found IONM services are not readily supported for use in lumbar spine 
procedures. Practice guidelines published by Sharan et al. (2014) reports, the data are insufficient to support a 
recommendation regarding the use of neuromonitoring as a modality that can be used for the preservation of 
nerve root function during lumbar fusion surgery (one Level IV study). Even current guidelines from the 
American Academy of Neurology (AAN) (Nuwer etal 2012) do not provide an indication for the use of 
IOMN in lumbar spine surgery. Rather, the case series used as part of the AAN analysis evaluated other 
surgery types (e.g cervical spine, vascular procedures, spinal tumors, etc.). In that regard, the AAN guidelines 
cannot be said to support the use of IONM in this case either. A recent retrospective database study by Ney et 
al. (2015) which advocated support for the use of IONM conceded, more research is needed to confirm these 
findings. The authors also noted a lack of RCTs (randomized controlled trials) on the use of IONM in such 
surgeries. It is also of note that the paper by Ney et al (2015) is in disagreement with a similar study by Cole et 
al (2014). Given the conflicting evidence to date and the overarching consensus that further study is necessary 
to evaluate the use of IONM in lumbar spine surgery, the requested service was not supported as medically 
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 Continuous intraoperative neurophysiology monitoring, from outside the 
operating room (G0453) have not been met. Therefore, we decided that the Plan does not have to pay for the 
Continuous intraoperative neurophysiology monitoring (IONM), from outside the operating room (G0453) 
provided on December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. 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 
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 a MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested robotic orthosis is not proven to be more beneficial for treatment of the 
enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post-stroke hemiparesis therapy, including constraint-induced movement therapy, 
conventional muscle strengthening, and Botox for spasticity if needed. There is insufficient evidence in the 
literature that the MyoPro orthosis will improve the long-term outcomes for the enrollee, improve hemiparetic 
arm function, or be safe for long-term use. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for 
date of service May 11, 2021. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360 and 88381. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360 and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360 and 88381 billed for date of service May 11, 2021.