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

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service September 3, 
2021. 
 
You asked the Plan to pay for procedure code 85060. You say that this was billed with an appropriate place of 
service. The Plan denied your request. The Plan says because this was billed with an outpatient hospital place 
of service on the claim, this is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that when procedure code 85060 is billed for a 
hospital outpatient, the hospital is responsible for paying the technical component of the service, and no 
separate payment is made for the technical component. In this case, you did not bill with either a professional 
component or a technical component modifier, indicating that you performed both components of code 85060.  
However, because the technical component of this code is not separately payable for hospital outpatients (and 
because you billed with a hospital outpatient place of service), this code cannot be paid as billed.  The Plan has 
stated that you may submit a corrected claim if you wish. 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 85060 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 85060 billed for date of service September 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient behavioral health services provided on 
November 16, 2021, and November 23, 2021. 
 
You asked the Plan to pay for the outpatient behavioral health services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says a licensed mental health 
counselor is not eligible to enroll in the Medicare program per Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
We looked at the case file and Medicare rules. In this case, the provider is a licensed mental health counselor 
and does not qualify as a mental health provider eligible for payment per Medicare guidelines. Therefore, we 
decided that the Plan does not have to pay for the outpatient behavioral health services provided on November 
16, 2021, and November 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant removal (20680) and total hip arthroplasty 
(27130) provided on August 10, 2021. 
 
You asked the Plan to pay for the implant removal (20680) and total hip arthroplasty (27130). The Plan denied 
your request. The Plan says CPT code 27130 is not supported in the medical record. The Plan also says that 
CPT code 20680 is not supported in the medical records submitted and would be considered inclusive to CPT 
code 27130. 
 
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 20680 is removal of implant; deep (eg, buried wire, pin, 
screw, metal band, nail, rod or plate). The CPT Code Manual definition of code 27130 is arthroplasty, 
acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or 
allograft. 
 
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 implant removal (20680) and total hip arthroplasty 
(27130). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for 
coverage. Our reviewer found that the operative report does not describe an arthroplasty. The operative report 
does not support CPT 27130, which would include the removal of implant. Although CPT code 20680 is not an 
add on code, in this case it is a part of a bigger procedure and would not be reported separately from CPT 
27130. 
 
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 implant removal (20680) and total hip arthroplasty (27130) have not been 
met. Therefore, we decided that the Plan does not have to pay for the implant removal (20680) and total hip 
arthroplasty (27130) provided on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis provided to the enrollee billed as L4002 on 
September 3, 2021. 
 
You asked the Plan to pay for this orthosis. You say that this claim should be paid. The Plan denied your 
request. The Plan says that based on the Medicare billing guidelines, code L4002 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due 
to the omission of an appropriate code. Therefore, we decided that the Plan does not have to pay for an orthosis 
provided to the enrollee billed as L4002 on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full hereditary cancel panel provided to the enrollee on 
March 30, 2021. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says this type of screening is not covered by Medicare. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. This testing was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for a full hereditary cancel panel provided to the enrollee on March 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient psychotherapy services provided to the enrollee on 
December 8, 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 must attempt to consult the attending or primary care physician about the services 
furnished and document the consent or declination date to consultations, and the date of consultations in the 
patients medical record. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for outpatient psychotherapy services provided to the 
enrollee on December 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
  
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. While you may benefit 
from physical therapy, and occupational therapy, your rehab can be safely provided at a lower intensity and 
alternate setting such as in a skilled nursing facility or in-home with services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on October 11, 2021, 
and billed under code G0482. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the medical records provided show less than 15 drug classes were performed. There is a 
more appropriate Healthcare Common Procedure Coding System (HCPCS) code G0481 that should be used to 
bill for service rendered. It is noted that multiple attempts were made to contact the provider for 
additional information.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the records provided do not support the 
billing of code G0482. Based on this information, we decided that Medicare rules for coverage of this service 
have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the 
enrollee on October 11, 2021, and billed under code G0482.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 3, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on June 11, 
2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is experimental, unproven, and not covered. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a review of the medical literature and clinical practice guidelines does not support the clinical utility of a 
broad somatic hematolymphoid panel in someone being evaluated for a hematologic malignancy. The review 
has determined that the services at issue in this case are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing services provided to the enrollee on June 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on October 20, 2021.
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 November 4, 2021, to December 3, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled 
nursing facility (SNF) level of care. 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. She 
was medically stable without any acute exacerbations of chronic medical problems. Her physical function was 
at or near her baseline and she could have received further services at a lower level of care. Admission to the 
nursing facility at a skilled level of care for inpatient skilled services was 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from November 4, 2021, to 
December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the culture by nucleic acid testing provided on January 11, 
2021. 
 
You asked the Plan to pay for the genetic culture testing. You say that the testing provided is medically 
necessary and should be paid. The Plan denied your request. The Plan says this was not billed with the correct 
POS code. 
 
 The Plan must follow Medicare rules. Medicare rules say that 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 genetic culture testing 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 the culture by nucleic acid testing provided on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on July 23, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this was not billed with an appropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 drug testing 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 the definitive drug testing provided on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the technical component of the surgical pathology services 
provided on September 10, 2021. 
 
You asked the Plan to pay for the surgical pathology technical component services. You say that this was 
medically necessary testing that should be paid. The Plan denied your request. The Plan says the POS reported 
does not match where the specimen was collected. 
 
 The Plan must follow Medicare rules. Medicare rules say that 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 surgical pathology technical component 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 the technical component of the surgical 
pathology services provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 15, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services provided on October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services provided on August 17, 2021. 
You asked the Plan to pay for the services provided. You say that the codes are payable. The Plan denied your 
request. The Plan says the billed codes cannot be verified. 
 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 20551 is Injection(s); single tendon origin/insertion. We 
find that CPT code 20551 is not supported in the medical record. There is a more comprehensive code available 
to describe the services provided to the enrollee.  
 
The file shows that CPT codes 62323 and 20553 were billed along with 20551. We find that codes 62323 and 
20553 may be eligible for payment when billed with code 20551. The medical records provided do not show 
that the service billed with the -59 modifier were distinct procedural services. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the injection services provided on August 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
September 4, 2021, to September 12, 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 DRG and principal diagnosis code are not supported.  
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 DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the enrollee was admitted and treated in the hospital for pneumonia. CR was 1.9 
(with a history of chronic kidney disease at baseline 1.7), with liver function and platelets normal. Blood 
pressure was stable, and there was no rise of 2 or more points on the SOFA score. This documented clinical 
presentation does not support the diagnosis of sepsis. The provided records therefore do not support the DRG 
871; however, DRG 193 would be most appropriate for this case.  
 
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 to the enrollee from September 4, 2021, to September 12, 2021.