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

 
We decided that the Plan does not have to pay for the genetic testing provided on June 7, 2022, billed with 
codes 87481, 87500, 87640, 87641, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is medically necessary testing. 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 
June 7, 2022, billed with codes 87481, 87500, 87640, 87641, 87651, 87653, and 87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on October 18, 
2022. 
 
You asked the Plan to pay for the urine culture. You say that this service was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted with 
a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 87086. Any codes which are not listed are considered not medically necessary for 
code 87086. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine culture have not been met. Specifically, this claim was submitted with diagnosis code D41.3 (neoplasm of uncertain behavior of urethra), which is not among those codes listed as medically 
necessary and appropriate for this service. Therefore, we decided that the Plan does not have to pay for the 
bacterial urine culture (87086) provided on October 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the request is not medically necessary because the enrollee can safely 
receive the services they need in other settings for example: a skilled nursing facility. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary 
care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 the enrollee needs assistance with ambulation. The 
Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care such as home 
health services. 
 
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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 8, 2020, to 
November 11, 2020, 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 the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 J96.01, described as acute 
respiratory failure with hypoxia. 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 documentation does not support the billed 
code. Our physician reviewer found that the enrollee is a 67-year-old male who presented to the hospital with 
shortness of breath and cough in the setting of chronic obstructive pulmonary disease (COPD) on home oxygen 
and metastatic lung cancer. Computed tomography showed pneumonia and bilateral pleural effusions. He was 
treated with low dose oxygen via nasal cannula, Intravenous antibiotics and fluids, and thoracentesis. 
Following initial treatment, oxygen saturation was 94% on room air in the emergency department with normal 
pulmonary effort without acute distress. They did not require high flow oxygen support, vent support, or bilevel 
positive airway pressure. The provided documentation, therefore, does not sufficiently support the diagnosis 
code billed.  
 
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 November 8, 2020, to November 11, 2020, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service August 16, 
2022. 
 You asked the Plan to pay for procedure code 99283. You say that the claim including code 99283 is a 
replacement claim and should not be denied as bundled. The Plan denied your request. The Plan says payment 
for code 99283 is bundled into payment for code 99284. 
 
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 99283 
is a column II code to column I code 99284. This claim has not been billed with an appropriate modifier to 
bypass the edit.  
 
In addition, you stated that this claim is a replacement claim.  However, on the electronic claim that you 
submitted, Box 22 (the location to indicate resubmission of a claim) is blank.  You did not enter in a code in 
this box indicating that the claim is a replacement claim. 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 99283 
billed for date of service August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on September 18, 
2022, and September 19, 2022. 
 
You asked the Plan to pay for subsequent hospital care (99233). You say that the attached medical record 
contains a detailed account of the history, examination and medical decision making provided. You say that the 
documentation supports the evaluation and management level of care billed. The Plan denied your request. The 
Plan says the medical records do not support a detailed interval history and medical decision making of high 
complexity. 
 
  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 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high 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 patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
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 subsequent hospital care (99233). Our reviewer says that the 
documentation does not support procedure code 99233 based on the key components in the code description. 
Our reviewer found there was no detailed history or medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of subsequent hospital care (99233) have not been met. Therefore, we decided that 
the Plan does not have to pay for subsequent hospital care (99233) provided on September 18, 2022, and 
September 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Prolia injection (J0897) and administration (96401). 
 
You asked the Plan to pre-approve a Prolia injection and administration. You say that it is medically necessary 
that the enrollee be treated for osteoporosis to minimize risk of future fractures. The Plan denied your request. 
The Plan says this request cannot be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
 
 
 
 
 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 Prolia injection and administration. 
Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. Our physician 
reviewer found the enrollee meets FDA criteria for Prolia use with the history of the sacral insufficiency 
fracture, except that provided records do not document lack of hypocalcemia. Hypocalcemia is a 
contraindication to use of Prolia; provided records do not report the enrollee's calcium level and do not report 
that they are on a calcium supplement. Our reviewer found that the use of Prolia for osteoporosis without ruling 
out hypocalcemia is not supported by one of the major drug compendia or by clinical research that appears in a 
Centers for Medicare & Medicaid Services (CMS) approved medical journal. The use of Prolia for osteoporosis 
without ruling out hypocalcemia is not indicated, supported or recommended in any of the compendia. Our 
physician reviewer also found that the use of Prolia for osteoporosis without ruling out hypocalcemia does not 
meet Medicare criteria for safe and effective and otherwise reasonable and necessary for this enrollee. 
 
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 Prolia injection and administration have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Prolia injection (J0897) and administration (96401).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (ECG) up to 30 days continuous with 
transmission of patient triggered events with review and report by health care professional (93229) provided on 
August 22, 2022. 
 
You asked the Plan to pay for the ECG. You say that the claim should be paid as billed. The Plan denied your 
request. The Plan says current procedural terminology (CPT) 93229 remains 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 93229 is an external mobile cardiovascular telemetry 
with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours 
of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports 
as prescribed by a physician or other qualified health care professional. 
 
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 ECG. Our reviewer says that the documentation does not 
support procedure code 93229.  Our reviewer found that there is no documentation substantiating that this 
procedure was performed. There is no report or evidence that an external telemetry with electrocardiographic 
recording was provided. There is no record of surveillance, support, or interpretation. 
 
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 ECG have not been met. Therefore, we decided that the Plan does not have 
to pay for an electrocardiogram (ECG) up to 30 days continuous with transmission of patient triggered events 
with review and report by health care professional (93229) provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Via Disc NP Allograft procedure. 
 
You asked the Plan to pre-approve Via Disc NP Allograft procedure. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 Via Disc NP Allograft procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was being treated for intervertebral disc degeneration of the 
lumbar region. The enrollee presented with low back pain with radiation into the left buttock that is aching, 
burning, stabbing, shooting, and rated at five out of 10. The enrollee notes weakness in the left leg. The lumbar 
spine exam reveals a moderately decreased range of motion. There is tenderness to palpation at the L3 spinous process. There is facet tenderness at L3/4, L4/5, and L5/S1 bilaterally. FABER is positive bilaterally. However, 
there is limited published, large-scale, long-term peer-reviewed literature that shows this request to be an 
effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this request 
has beneficial outcomes compared with conventional treatment. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
enrollee does not meet criteria for the requested 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 Via Disc NP Allograft procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Via Disc NP Allograft procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection (62321) provided on December 20, 2022. 
 
You asked the Plan to pay for the injection (62321). You say that the claim billed for diagnosis code M54.12 
and there have been no other services performed in treatment of that diagnosis. You say that the claim denied 
in error and should be reconsidered. The Plan denied your request. The Plan says procedure code 62321 is 
included within the global surgery package of procedure code 64635. 
 
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 62321 is injection(s), of diagnostic or therapeutic 
substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with 
imaging guidance (ie, fluoroscopy or CT). 
 
We find that CPT code 62321 is not supported in the medical record. Specifically, there is no indication this 
service was unrelated to the procedure performed on December 14, 2022. Based on this information, we 
decided that Medicare rules for coverage of the injection (62321) have not been met. Therefore, we decided 
that the Plan does not have to pay for the injection (62321) provided on December 20, 2022.
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 enrollee is a fall risk and in danger of re-
hospitalization. The Plan denied your request. The Plan says the enrollee's records do not show that you need 
an intensive team and medical conditions are stable, services needed can be provided safely in other settings, a 
skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 may benefit from physical and occupational therapy, rehabilitation needs 
can be provided in a lower intensity and alternate setting such as 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 lab services provided on May 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and you are 
the only lab that performs this service. 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 May 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thyroid uptake measurement (78012). 
 
You asked the Plan to pre-approve a thyroid uptake measurement. The Plan denied your request. The Plan says 
this request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a thyroid uptake measurement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a 1.5-centimeter thyroid nodule. The thyroid-stimulating 
hormone is normal, and biopsy is planned. Our reviewer found that there is no indication for a thyroid uptake 
and scan. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a thyroid uptake measurement have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a thyroid uptake measurement (78012).