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

 
We decided that the Plan does not have to pay for procedure code(s) 88360 and 88381 billed for date of service 
February 15, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360 and 88381. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360 and 88381. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360 and 
88381. Based on this information, we decided that Medicare rules for coverage of procedure code 88360 and 
88381 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88360 and 88381 billed for date of service February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that hyperbaric oxygen therapy is 
medically necessary. The Plan denied your request. The Plan says hyperbaric oxygen therapy does not meet the 
Medicare coverage criteria. 
 The Plan follows Medicare rules.  
 
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 hyperbaric oxygen therapy. Our 
reviewer says that hyperbaric oxygen therapy is not medically necessary in this case. Our physician reviewer 
found that in this case, the record indicates that you have urothelial carcinoma of bladder and underwent 
transurethral resection of the bladder tumor. The record does not indicate the presence of radiation cystitis or 
radionecrosis. The elements of the coverage criteria are not satisfied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for date of service August 19, 
2022. 
 
You asked the Plan to pay for procedure code 0245U. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 0245U is bundled into payment for code 0018U. 
 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 0245U 
is a column II code to column I code 0018U. 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 0245U billed for date of service August 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service April 27, 
2022. 
 
You asked the Plan to pay for procedure code 93971. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
The file shows that the enrollee received a duplex scan of the left upper extremity and a duplex scan of the left 
lower extremity. The services at issue were billed with CPT code 93971. In this case, the MUE for CPT code 
93971 is 1. The MAI value for this code is 3. You billed 2 units of this code, exceeding the MUE. The records 
provided do not show that the services were correctly coded. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 93971 billed for date of service April 27, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation and mileage provided on 
January 23, 2022. 
 
You asked the Plan to pay for the ambulance transportation and mileage. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 11, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the ambulance transportation and mileage 
have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation 
and mileage provided on January 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88360, 88361, and 88341 billed for date of 
service January 31, 2022. 
 You asked the Plan to pay for procedure codes 88360, 88361, and 88341. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says this code is included in the facility payment and is 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88360, 88361, and 
88341. This means there is both a professional and technical component for the CPT codes. In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT codes 88360, 88361, 
and 88341. Based on this information, we decided that Medicare rules for coverage of procedure code 88360, 
88361, and 88341 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 88360, 88361, and 88341 billed for date of service January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on April 8, 2022. 
 
You asked the Plan to pay for the general health panel. You say that this service is not medically necessary. 
The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening laboratory tests (81329, 81220, 81420) provided 
on June 30, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says these services were performed in the absence of signs, symptoms, complaints, personal history or injury for this enrollee. This laboratory testing was performed for screening 
purposes but does not qualify as a covered screening under 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. 
 
The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these 
tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for screening 
laboratory tests (81329, 81220, 81420) provided on June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on August 29, 
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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for the computed tomography (CT) scan rendered on August 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device, four or more leads, for multiple nerve stimulation (E0730) and electrical stimulator supplies, 2 lead, per 
month, (e.g., TENS, NMES) (A4595) provided June 13, 2022. 
 
You asked the Plan to pay for the Tens device and supplies. You say that according to the prescription, the 
prescribing physician recommends an extended lifetime use of equipment as they are diagnosed with chronic 
pain and compromised mobility without the option for surgical correction. The Plan denied your request. The 
Plan says evidence of misrepresented services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.   
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, outreach was made to provider's office indicated 
on the claim and the Plan confirmed that the doctor did not order the device and supplies for the enrollee. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation 
(TENS) device, four or more leads, for multiple nerve stimulation (E0730) and electrical stimulator supplies, 2 
lead, per month, (e.g., TENS, NMES) (A4595) provided June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care services provided on October 29, 2021, 
and October 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 payment for CPT codes 99218 and 99224 is not supported in the medical record. Specifically, 
these codes are used for outpatient observation care. It is inappropriate to bill outpatient observation care codes 
with an inpatient place of service (POS 21). 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 
observation care services provided on October 29, 2021, and October 30, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Cancer Type ID genetic testing. 
 
You asked the Plan to pre-approve Cancer Type ID genetic testing. You say that the requested genetic testing is 
medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for 
the requested genetic testing. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 Cancer Type ID genetic testing. Our 
reviewer says that the requested genetic testing is medically necessary. Our physician reviewer found the 
NCCN guidelines for occult malignancy 3.2023, page OCC-2, consider tumor/somatic molecular profiling for 
patients who are candidates for anti-cancer therapy to identify uncommon mutations (ie, RET fusions). Testing 
on tumor tissue is preferred; however, cell-free DNA testing can be considered if tumor tissue testing is not 
feasible. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cancer Type ID genetic testing have been met. Therefore, we decided that the 
Plan has to pre-approve Cancer Type ID genetic testing.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PuraPly skin substitute. 
 
You asked the Plan to pre-approve PuraPly skin substitute. You say that PuraPly skin substitute is medically 
necessary. The Plan denied your request. The Plan says PuraPly skin substitute is experimental and 
investigational. 
 
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 PuraPly skin substitute. Our reviewer 
says that the requested PuraPly skin substitute is not considered medically reasonable and necessary. Our 
physician reviewer found you have a right calf chronic non-healing venous ulcer. It was treated with 
debridement, compression, collagen, and general wound care with benefit starting in November 2022. 
However, there is no recent documentation showing benefit or failure of conservative treatment and other more 
updated clinical information to help support this request for PuraPly. Therefore, without sufficient support 
made, this request for such will be considered not medically necessary at this time.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PuraPly skin substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve PuraPly skin substitute.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 27, 
2022. 
 
You asked the Plan to pay for the orthosis. You say that the claim denied for records not received, however you 
did not receive a records request. The claim meets the Medicare LCD requirements for lumbar-sacral orthosis. 
The Plan denied your request. The Plan says the claim must be submitted to the Primary carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the claim must be 
submitted to the primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for the 
orthosis until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for the lumbar-sacral orthosis (L0650) provided September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 5, 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 this service is medically necessary. The Plan denied 
your request. The Plan says this service is 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 your medical conditions are stable and there are no complex nursing or rehabilitation 
needs. While you may have a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program.   
 
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. Specifically, medically necessary services can be 
obtained in a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we 
decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and 
services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation beyond the Plan's 50-mile trip 
limit. 
 
You asked the Plan to pre-approve routine transportation beyond the Plan's mileage limit. You say that you 
need to travel to this provider's office and do not have anyone to take you. The Plan denied your request. The 
Plan says the requested trip is beyond the mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 50 miles of driving distance per one way trip. 
 We looked at your request, the records in the case file, and the rules. The requested trip exceeds 50 miles of 
driving distance. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine 
transportation beyond the Plan's 50-mile trip limit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. All medically necessary care is being provided in the 
current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.