Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99283 provided on 
June 11, 2022. 
 
You asked the Plan to pay for the emergency department visit. 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. 
 
In this case, the CPT Code Manual definition of code 99283 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: An expanded problem focused history; 
An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate severity. 
 
 We find that CPT code 99283 is not supported in the medical record. Specifically, this service was billed with 
place of service 49 (independent clinic). This billed place of service is not compatible with the billed code. 
Based on this information, we decided that Medicare rules for coverage of the emergency department visit have 
not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit 
coded 99283 provided on June 11, 2022.
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 their primary doctor believes skilled therapy is 
necessary due to frequent falls at home, inability to manage day to day activities safely, poor balance, 
decreased strength and endurance. The Plan denied your request. The Plan says the SNF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as home with home health, in 
residential care, or home with close follow-up with your doctor.  
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (12034) provided on July 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 12034 is "Repair, intermediate, wounds of scalp, axillae, 
trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm". 
 
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 services. Our reviewer says that the use of code 12034 is 
not supported by the records provided. Our reviewer found that the procedure report documents "Final defect 
(lesion plus margin) was 10 mm and final length for repair was 5 cm". In this case, wound repair for 7.6 to 12.5 
centimeters cannot be verified, as the documentation supports wound repair was 5 cm. There is a more 
appropriate code to report for this level of service. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (12034) provided on July 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedure is experimental. More research is needed to show safety and 
efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
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 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 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 to the hospital on November 26, 2022 with foot pain and 
atrial fibrillation. The IRF screening on December 6, 2022 states he needs minimal assist of two for bed mobility and minimal assist for transfers. He is dependent for less than 50 feet of ambulation. He does not 
require the intensity of services in an IRF. Specifically, he is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The IRF services are not reasonable or 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 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 lab services (83789, G0480) provided on June 20, 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 this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
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, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for lab services (83789, G0480) provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service September 
21, 2021. 
 You asked the Plan to pay for procedure code 99213. The Plan denied your request. The Plan says payment for 
code 99213 is bundled into payment for code G0439. 
 
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 99213 is a column II code to column I code G0439. 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 99213 
billed for date of service September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrodes (A4595), and lead wires (A4557), provided on 
May 31, 2022. 
 
You asked the Plan to pay for the electrodes and lead wires. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that separate allowance will be made for replacement 
supplies when they are reasonable and necessary and are used with a covered TENS. 
 
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 electrodes and lead wires. Our reviewer 
says that the items are not medically necessary. Our physician reviewer found the records are insufficient to 
support the medical necessity of the requested number of units of the requested service. 
 
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 electrodes and lead wires have not been met. Therefore, we decided that the 
Plan does not have to pay for the electrodes (A4595), and lead wires (A4557), provided on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on May 24, 2022. 
 You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported as billed. 
The Plan denied your request. The Plan says there is insufficient information in the record to show that this test 
was performed as ordered and was medically necessary. 
 
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 drug testing have been met. 
Specifically, the order form provided does not include a request for drugs from 22 or more classes or clearly 
state which specific drugs are ordered for testing. Therefore, we decided that the Plan does not have to pay for 
definitive drug testing (G0483) provided on May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted multinalyte assay with algorithmic analysis 
(81599) provided May 14, 2022. 
 
You asked the Plan to pay for the Nodify CDT test. You say that the doctor regarded the Nodify CDT test as a 
medically necessary and valuable tool when determining treatment for the enrollee. The Plan denied your 
request. The Plan says the requested procedure is considered investigative or experimental due to a lack of 
safety and efficacy or effects on health care outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Nodify CDT test have not been met. Therefore, we decided that the Plan does not have to pay 
for the unlisted multinalyte assay with algorithmic analysis (81599) provided May 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service June 27, 
2022. 
 You asked the Plan to pay for procedure code 99222. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99222 is bundled into payment for code 99152. 
 
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 99222 
is a column II code to column I code 99152. 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 99222 billed for date of service June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 7, 2022, billed with 
codes 81206, 81210, 87235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194 and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and 
appropriate. 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 
February 7, 2022, billed with codes 81206, 81210, 87235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 
81401, 81194 and 81309.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 55 additional units of procedure code J2997 provided to the 
enrollee on August 17, 2022. 
 
You asked the Plan to pay for the additional units. You say that this was medically necessary. The Plan denied 
your request. The Plan says 55 units of J2997 cannot be reimbursed. 
 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 procedure code J2997 is "Injection, alteplase recombinant, 1 
mg." 
 
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 additional units. Our reviewer says that the services a 
tissue in this case were not supported by the medical records. Our reviewer found that per the medical records 
submitted, there was 45 units of J2997 administered and 55 units of J2997 discarded. Per Medicare rules, the 
discarded portion of J2997 should be billed on a separate line with JW modifier. 
 
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 additional units have not been met. Therefore, we decided that the Plan does 
not have to pay for 55 additional units of procedure code J2997 provided to the enrollee on August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99253 billed for date of service June 15, 
2022. 
 
You asked the Plan to pay for procedure code 99253. You say that the service was medically necessary. 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 99253 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99253 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99253 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99253 billed for date of service June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) testing panel provided on 
July 12, 2022. 
 
You asked the Plan to pay for the UTI panel. You say that this testing was medically necessary and reasonable. 
The Plan denied your request. The Plan says this claim was not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infectious disease pathogen identification testing have not been met. Specifically, the records show 
that a single panel was ordered and performed, but this service was billed by reporting individual components. 
Therefore, we decided that the Plan does not have to pay for the urinary tract infection (UTI) testing panel 
provided on July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology (81479) provided on March 
1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that AlloSure Heart was medically necessary, 
not experimental and investigational, and is used in clinical practice to aid in the management of the enrollee. 
The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network 
provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the unlisted molecular pathology (81479) provided 
on March 1, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and 
supplies (K0553). 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says the member does not use insulin with at least three daily injections and 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oxygen supplies provided on June 29, 
2022, to August 29, 2022. 
 
You asked the Plan to waive the coinsurance for oxygen supplies. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies. The allowed amounts of these oxygen supplies 
total $263.65, resulting in a total coinsurance amount of $52.73. 
 
You have been asked to pay 20% coinsurance for oxygen supplies. This item/service falls within the durable 
medical equipment and related supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for oxygen supplies provided on June 29, 2022, to August 29, 2022.