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

 
We decided that the Plan does not have to pay for procedure code 81455 billed for March 28, 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 procedure code 81455 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the file shows that a targeted 
genomic sequence panel of 5 to 50 genes was performed and there is a more appropriate code for these 
services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81455 billed for March 
28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service from 
August 13, 2022, to September 9, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the services at issue have been billed 
correctly. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service from August 13, 2022, to September 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not support a need for a skilled nurse to make more visits. 
 
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 that the 
provided records do not document any acute or unstable medical conditions or injuries or changes in 
medication or treatment which would necessitate any further skilled nursing visits beyond what have already 
been approved. Records document the caregiver has been educated on his disease process, safety measures and 
his medications. No medical notes from the enrollee's treating physician are provided documenting an order or 
need for additional skilled nursing services. Records do not document the need for intravenous medications, 
new tube feeding or ostomy care or daily complex wound 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 nine additional home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the home ventilator is being requested for use in intelligent volume assured pressure support (IVAPS) 
mode with auto-titration (AE) which could be provided by a BiPAP device with average volume assured 
pressure support (AVAPS) and a back-up rate. Ventilators used to provide BiPAP therapy are not covered. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 the enrollee was admitted for sepsis and osteomyelitis. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99225 billed for date of service September 
21, 2022. 
 You asked the Plan to pay for procedure code 99225. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 99225 is bundled into payment for 
code 99226. 
 
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 99225 
is a column II code to column I code 99226. 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 99225 billed for date of service September 21, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new power wheelchair with accessories (K0836, E1002, 
E1028, E2310, E2361). 
 
You asked the Plan to pay for a new power wheelchair with accessories. You say that your current PWC is 
completely broken. The Plan denied your request. The Plan says your current power wheelchair (PWC) is two 
years old. The records do not show why a replacement is needed instead of repair of the current PWC. 
 The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical 
equipment cannot be less than 5 years. Replacement due to wear is not covered during the reasonable useful 
lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover repair up to the cost of 
replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary. 
 
We looked at the file and Medicare rules. Your current power wheelchair is two years old. This is less than the 
reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of a new 
power wheelchair with accessories have not been met. Therefore, we decided that the Plan does not have to pay 
for a new power wheelchair with accessories (K0836, E1002, E1028, E2310, E2361).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total disc arthroplasty (22856/22858). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for arthropathy and neck pain. He presented with continued pain in 
the neck and right arm. The exam reveals no significant deficit. He has movement of his neck, but has pain. 
 
The Food and Drug Administration inclusion criteria includes a diagnosis of degenerative cervical 
radiculopathy with or without spinal cord compression requiring surgical treatment at two contiguous levels 
from C3 to C7 demonstrated by signs and/or symptoms of disc herniation and/or osteophyte formation and is 
confirmed by patient history and radiographic studies. Exclusion criteria included previous anterior/posterior 
cervical spine surgery.   
However, detailed documentation is not evident regarding a trial and failure of recent, reasonable, 
comprehensive less invasive conservative care measures (outside of epidural injections). The current pain level 
was not clearly documented to be greater than or equal to 4 on the visual analog scale (VAS). There is no 
corroboration of radiculopathy on the objective findings on the recent examinations.  
 
Additionally, diagnostic imaging is not provided to rule out osteoporosis. There is no detailed medical history 
provided to rule out other medical history of endocrine or metabolic disorder; Fibromyalgia, Rheumatoid 
Arthritis (or other autoimmune disease), or a systemic disorder such as human immunodeficiency virus (HIV) 
or acute hepatitis B or C; or insulin-dependent diabetes mellitus. There are limited large-scale, long-term 
references showing the safety and efficacy of the requested surgery in this clinical setting. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested service 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a total disc arthroplasty (22856/22858).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have submitted medical records to support 
payment. 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 July 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for September 27, 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 procedure code G0483 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
show that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code G0483 billed for September 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance angiography, neck; without 
contrast material(s), followed by contrast material(s) and further sequences (70549). 
 You asked the Plan to pre-approve an MRA of the neck. You say that you disagree with the denial. The Plan 
denied your request. The Plan says results of the prior approved study are needed to show the need for repeat 
imaging, or the doctor must confirm that the prior approved study was not performed. 
 
The Plan must follow Medicare rules. Medicare rules say that MRAs 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 an MRA of the neck. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has migraines and 
possibly had a TIA. The records provided for review indicated that the index episode had been in the past. It 
was not otherwise demonstrated that in the records that the enrollee had a condition of the head and neck for 
which surgery is anticipated and may be found to be appropriate based on the MRA. There was no 
documentation to suggest that the enrollee otherwise has a need for any acute intervention at this time. Nor was 
there documentation of a condition that would improve from provision of said service. In as much, this would 
not meet criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA of the neck have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance angiography, neck; without contrast material(s), followed 
by contrast material(s) and further sequences (70549).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspiration (20939). 
 
You asked the Plan to pre-approve this service. You say that the requested service is medically necessary for 
the enrollee. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for spondylolisthesis of the lumbar region. He presented with low 
back pain with pain radiating to the bilateral legs. There is numbness of both feet. The pain is constant. The 
exam reveals lumbar muscle spasms with severely reduced range of motion. There is left lower extremity 
weakness and numbness. Bladder incontinence is noted. The health plan approved the inpatient L2-5 anterior 
lumbar interbody fusion with posterior instrumentation. 
 
However, there is no specific indication provided to support the request for bone marrow aspirate for the 
approved surgery.  There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow 
aspirate for this enrollees medical condition. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
bone marrow aspiration, in this case, 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on May 4, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that the service should be covered. The 
Plan denied your request. The Plan says proof of payment was not submitted. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency room services have not been met. Specifically, reimbursement cannot be made 
without proof of payment. Therefore, we decided that the Plan does not have to pay for the emergency room 
services provided on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95887 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for procedure code 95887. You say that the services at issue have been billed 
correctly. 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 95887 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 95887 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 95887 billed for date of service June 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 21, 2022, to 
September 19, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 21, 2022, to 
September 19, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882-26 billed for date of service July 21, 
2022. 
 
You asked the Plan to pay for procedure code 76882-26. You say that the claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 76882-26 is bundled into payment for 
code 93925. 
 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 
76882-26 is a column II code to column I code 93925. 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 76882-26 billed for date of service 
July 21, 2022.