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

 
We decided that the Plan has to pay for the FANCC and BLM genetic testing rendered on October 20, 2021. 
 
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 that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan references Local Coverage Articles (LCA) A55183 and A55113 in their 
determination; which are not binding for the services at issue and is superseded by National Coverage 
Determination (NCD) 90.2, which allows for coverage of this testing. Therefore, we decided that the Plan has 
to pay for the FANCC and BLM genetic testing rendered on October 20, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services rendered on September 23, 
2021. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is made for an assistant at surgery when 
the procedure is authorized for an assistant and the person performing the service is a physician, physician 
assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS). 
 
We looked at the file and Medicare rules. Review of the record shows that the provider is not a physician, PA, 
NP, or CNS. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
rendered on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies rendered on November 23, 2021. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any durable medical equipment (DME) item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 the wound care supplies rendered on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on January 28, 2022. 
 
You asked the Plan to pay for this claim as billed. You say that these lab services should be covered by the 
Plan. The Plan denied your request. The Plan says this claim was not submitted with the appropriate Place of 
Service code. The Plan states several attempts were made to have this corrected and a new claim would be 
reviewed if submitted.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case it has been confirmed that this claim 
does not reflect the appropriate POS code. Therefore, we decided that the Plan does not have to pay for lab 
services provided to the enrollee on January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (CX Bladder testing) provided to the enrollee on 
February 2, 2022. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare coverage criteria were not 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 pay for this testing. Our 
reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our 
physician reviewer found CxBladder is not considered a screening test for urothelial cancer. If urothelial cancer 
is suspected, cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary 
regardless of the results of Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-
negative results in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is 
poor for low-stage and low-grade tumors. Medical necessity is not established.  
 
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 testing have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (CX Bladder testing) provided to the enrollee on February 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 2, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered on June 7, 2021, to 
June 20, 2021. 
 
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 there is no itemized bill for the services. 
 
The Plan must follow Medicare rules. The rules say that outlier cost cases are require medical records and 
itemized charges for verification of services. 
 
We looked at the file and Medicare rules. The file shows that an itemized bill was not received for verification 
of the payment recoupment. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
services rendered on June 7, 2021, to June 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service December 
20, 2021. 
 
You asked the Plan to pay for procedure code 71045. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 71045 is bundled into payment for code 36573. 
 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 71045 
is a column II code to column I code 36573. 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 71045 billed for date of service December 20, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional radiology services (procedure code 74230) 
provided to the enrollee on November 12, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records submitted do not indicate that two separate services were performed. 
 
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 74230 is "Radiologic examination, swallowing function, 
with cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when 
performed, contrast (eg, barium) study." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the records show that only a 
single modified barium swallow was done on the denied date 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 additional radiology services (procedure code 74230) provided to the enrollee on November 12, 
2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on February 17, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied codes remain 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 
the denied codes is: 
 
CPT 20931: 
 
Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) 
 
CPT 22859: 
 
Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to 
intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List 
separately in addition to code for primary procedure) 
 
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 services at issue in 
this case were supported by the medical records. Our reviewer found that the records do not support that the 
denied codes were actually rendered in this case. The enrollee was being treated for other intervertebral disc 
degeneration of the lumbar region; and lumbago with sciatica. He underwent an L2-3 oblique interbody fusion; 
complete L2-3 discectomy; restoration of disc height; L2-3 anterolateral integrated plate instrumentation, screw 
fixation, arthrodesis, and use of allograft on 2/17/22. The procedure notes that the interbody was filled with 
allograft and secured to an angled instrument. It further notes that the plate was sized and placed with 39mm 
screws to secure the plate and interbody in place. Therefore, the records do support these codes. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services provided to the enrollee on February 17, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 7 home health skilled nursing visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
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 7 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documented home health skilled nursing needs. As such, the requested, ongoing, home health 
skilled nursing services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 7 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 7 home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography services (procedure codes 75710, 75774) 
provided to the enrollee on March 1, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 75710: 
 Angiography, extremity, unilateral, radiological supervision and interpretation  
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the ultrasound had shown 
occlusion of the right superficial femoral artery, and the procedure 37225 would have included selective 
angiograms of the arteries of the right lower extremity as part of the interventional procedure and as such 
cannot be billed separately. 
 
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 angiography services (procedure codes 75710, 75774) provided to the enrollee on March 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that the standard wheelchair that was approved is 
too small. The Plan denied your request. The Plan says there are standard wheelchairs that are wide enough to 
prevent irritation. 
 
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 wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that based on the medical records provided there is no documentation that the enrollee has a 
condition to indicate a heavy duty wheelchair as determined by Medicare criteria. The provided records show 
that you weigh 190 pounds with no documentation of severe spasticity. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heavy duty wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoe balancer purchased on October 29, 2020. 
 
You asked the Plan to pay for the item. You say that this should be paid for. The Plan denied your request. The 
Plan says out-of-network durable medical equipment was purchased. 
 
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 a shoe balancer purchased on October 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on February 22, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records and claim information submitted must corroborate the documentation in the 
beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. The Provider 
has not submitted clinical information to support the services billed. The Plan cannot determine how the 
enrollee came to the servicing provider, or whether the services were 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 lab services provided to the enrollee 
were met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on 
February 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 1, 2021, to November 10, 2021. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says supervision could have been provided at the long-term care facility where the enrollee is 
a resident. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for 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 that based on the medical records provided there is no documentation that the patient 
required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse were not required to safely and effectively provide medically necessary and reasonable treatment from 
11/01/2021 through 11/10/2021. The records did not document the need for intravenous medications, new tube 
feeding or ostomy care or daily complex wound care or respiratory care. Daily skilled nursing or therapy 
services were not required during the period in question. The patient was walking greater than household 
distances with contact guard to stand-by assistance with no reported assistive device and was contact guard to 
stand-by assist for transfers. The enrollee's needs in the nursing facility appears custodial during this time 
period. Care could have been provided in the long-term care facility.  
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from November 1, 2021, to 
November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided the Plan does not have to pay for lab services coded as 87481, 87653, 87798-91, and 87641-91.  
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says while codes 87801-91 and 87500-91 were paid, codes 87150-91, 87481, 87653, 87798-
91, and 87641-91 are included in the payment of 87801 and 87150 and cannot be billed or paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case codes 87481, 87653, 87798-91, and 
87641-91 cannot be separately billed due to their bundled relationship with the approved codes. Therefore, we 
decided that the Plan does not have to pay for lab services coded as 87150-91, 87481, 87653, 87798-91, and 
87641-91.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 16, 2022. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim has not been billed correctly based on the Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. We looked at the file and Medicare rules. In this 
case, the services provided should have been billed as a single procedural service.  
  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 genetic testing provided to the enrollee on March 
16, 2022.