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

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, and 88360 billed for date of 
service March 22, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, and 88360. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these services 
were not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that procedure codes 88341, 88342, and 88360 are physician pathology services which have both 
professional components (PC) and technical components. These services were not billed with modifier 26 to 
indicate that only the professional component payment is requested. This means that payment is requested for 
both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
outpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88341, 88342, and 88360 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 88341, 88342, and 88360 billed for date of service March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a segmental gradient pressure pneumatic appliance, half leg 
(E0673) and a pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial 
insufficiency (E0675) provided on April 20, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you disagree with 
the denial and are requesting reconsideration. The Plan denied your request. The Plan says the requested device 
is not eligible for reimbursement. There is insufficient evidence to demonstrate that reimbursement is justified. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a segmental gradient pressure pneumatic appliance, half leg (E0673) and a pneumatic compression 
device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (E0675) provided on April 20, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on April 8, 2022, to 
April 11, 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 you 
disagree with the Plans 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, M47.16, defined as other 
spondylosis with myelopathy, lumbar region. 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that the documentation does not 
support that DRG billed. Our physician reviewer found the enrollee was admitted following elective total 
elbow arthroplasty. The Hospital Pharmacist documented the enrollee's past medical history as including 
"Spondylosis Lumbar Without Myelopathy". The Occupational Therapist documented the enrollees past 
medical history as including "Spondylosis Lumbar Without Myelopathy". The Physical Therapist documented 
the enrollee's Past Medical History as including "Spondylosis Lumbar Without Myelopathy". The Diabetes 
Nurse Educator documented a history of "lumbar spondylosiswith myelopathy". The Infectious Disease 
consultant did not comment on the enrollees history of spondylosis. The admitting Orthopedic Surgeon did not 
comment on the enrollee's history of spondylosis. The enrollee was continued on his home medications, 
including Flexeril, Cymbalta, and Neurontin, all medications commonly used to treat symptoms of 
fibromyalgia. diagnosis other spondylosis with myelopathy, lumbar region (M47.16) was not supported by the 
documentation. The DRG billed was not supported by the documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 8, 2022, to April 11, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted to the hosiptal on December 5, 2022 with lower extremity 
pain and swelling. She is now walking greater than 100 feet with a wheeled walker and stand-by assistance. 
She needs stand-by to minimum assistance for activities of daily living. She does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. She has 
lower extremity ulcerations but does not require skilled nursing services on a daily basis. The enrollee does not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours per week of home health aide (HHA) 
services. 
 
You asked the Plan to pre-approve additional hours of HHA services. The Plan denied your request. The Plan 
says this request is denied because it is not considered medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 additional hours of HHA services. Our 
physician reviewer found the clinical documentation does not specify any clinical or functional status change 
(only referral to neurology), thus additional hours of HHA services are not 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 additional hours of HHA services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional hours per week of home health aide (HHA) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4556, A4649, and 93005, billed for date of 
service July 19, 2022. 
 
You asked the Plan to pay for procedure codes A4556, A4649, and 93005. The Plan denied your request. The 
Plan says these codes are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure codes A4556 and A4649 have a status indicator of P on the Physician Fee Schedule. 
This means that procedure codes A4556 and A4649 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes A4556 and A4649 have not been met. 
 
We also find that payment for CPT code 93005 is not supported in the medical record. Specifically, code 93005 
is assigned a PC/TC indicator of 3. As such, there is only a technical component for this code, and the 
professional interpretation is not payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 93005 has not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes A4556, A4649, and 93005, billed for date of service July 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission after December 5, 2022. 
 
You asked the Plan to pre-approve inpatient admission after December 5, 2022. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services are 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 inpatient admission after December 5, 
2022. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found as of December 5, 2022, the enrollee is medically stable. 
The enrollee continues to require oversight monitoring due to slowly resolving expressive aphasia, but this care 
can be given at an alternate level of 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 inpatient admission after December 5, 2022, have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient admission after December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82570 and 83986 billed for date of service 
April 25, 2022. 
 
You asked the Plan to pay for procedure code 82570 and 83986. You say that say the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says payment for codes 
82570 and 83986 is bundled into payment for current procedural terminology (CPT) code 80307 and healthcare 
common procedure coding system (HCPCS) code G0481.  
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 82570 
and 83986 is a column II code to column I code current procedural terminology (CPT) 80307 and healthcare 
common procedure coding system (HCPCS) code G0481. 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 codes 82570 and 83986 billed for date 
of service April 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supplies provided on June 16, 2022. 
 
You asked the Plan to pay for the TENS supplies. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the items rendered are not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. While there was a 
packing slip in the case file, the enrollee could not verify that they received the items in June. The tracking 
screenshot does not include the full delivery address. This means that the proof of delivery is invalid. 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 the transcutaneous electrical nerve stimulation 
(TENS) supplies provided on June 16, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emissions tomography (PET) scan with computed 
tomography (CT) scan (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is not covered for initial management of prostate cancer. 
 
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 a PET/CT scan. Our reviewer says that 
the service is medically necessary and reasonable for the enrollee at this time. Our physician reviewer found in 
patients with prostate cancer at high risk for metastatic disease with negative conventional imaging, clinicians 
may obtain molecular imaging to evaluate for metastases. 
 
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 PET/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emissions tomography (PET) scan with computed tomography (CT) scan (78815).  
 
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 codes 88361, 88312, 88305 and 88112 billed for 
date of service December 27, 2021. 
 
You asked the Plan to pay for procedure codes 88361, 88312, 88305 and 88112. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says these 
services were not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that procedure codes 88361, 88312, 88305 and 88112 are physician pathology services which have 
both professional components (PC) and technical components. These services were not billed with modifier 26 
to indicate that only the professional component payment is requested. This means that payment is requested 
for both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
outpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88361, 88312, 88305 and 88112 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88361, 88312, 88305 and 88112 billed for date of service December 27, 
2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing for antibody screen, RBC, each serum technique, 
Lipid panel for Cholesterol, serum, total Lipoprotein, direct measurement, high density cholesterol (HDL 
cholesterol) Triglycerides, Blood typing, serologic; ABO, Basic metabolic panel (Calcium, total), Carbon 
dioxide (bicarbonate), Chloride, Creatinine, Glucose, Potassium Sodium Urea nitrogen (BUN) provided from 
August 18, 2022, to August 19, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that the laboratory testing was ordered by the 
enrollee's physician and was due to an emergency hospital admission. The Plan denied your request. The Plan 
says that the services were not allowed per Medicare guidelines. 
 
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. Specifically, the Plan has not provided us with the rules used to make their 
decision. Therefore, we decided that the Plan has to pay for laboratory testing for antibody screen, RBC, each 
serum technique, Lipid panel for Cholesterol, serum, total Lipoprotein, direct measurement, high density 
cholesterol (HDL cholesterol) Triglycerides, Blood typing, serologic; ABO, Basic metabolic panel (Calcium, 
total),Carbon dioxide (bicarbonate),Chloride, Creatinine, Glucose, Potassium Sodium Urea nitrogen (BUN) 
provided from August 18, 2022, to August 19, 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 the genetic testing provided on March 9, 2021, billed with 
codes 81194, 81317, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, and 
81311. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and 
reasonable for the enrollee's condition. 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 
March 9, 2021, billed with codes 81194, 81317, 81321, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 
81295, 81298, 81301, and 81311.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99503 billed for date of service April 26, 
2022. 
 
You asked the Plan to pay for procedure code 99503. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 99503 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99503 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99503 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99503 billed for date of service April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection 
(TFESI) (64483). 
 
You asked the Plan to pre-approve repeat TFESI. You say that the enrollee had a TFESI done on August 16, 
2022. You say that they reported 70% relief total. You say that the enrollee's pain has returned. You also say 
that the enrollee has trialed activity modifications, medications, and home exercises. The Plan denied your 
request. The Plan says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat epidural steroid injection (ESI) is medically 
necessary when the first injection directly and significantly provided at least 50% pain relief for at least three 
months. 
 
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 repeat TFESI. Our reviewer says that a 
repeat TFESI is not medically necessary. Our physician reviewer found the provided documentation does not 
support that the enrollee has experienced at least 50% pain relief for three months. Therefore, the reviewer 
found that a repeat injection is not 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 repeat TFESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat transforaminal epidural steroid injection (TFESI) (64483).