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

 
We decided that the Plan does not have to pay for the surgical assistant services provided during a knee 
procedure on November 12, 2021, billed with code 29882. 
 
You asked the Plan to pay for the assistant services as billed. You say that the surgeon requested an assistant, 
and the procedure could not be done without one. The Plan denied your request. The Plan says surgical 
assistant services are not paid by Medicare for this code. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 29882. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
assistant services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
surgical assistant services provided during a knee procedure on November 12, 2021, billed with code 29882.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 24, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says the requested 
documentation/medical records to develop this claim has not been received timely. 
 
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 physician's services provided on August 24, 2021 have been met. Therefore, we decided that the Plan does not have to pay for physician's 
services provided on August 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a biopsy or excision of lymph nodes (38510) provided on 
December 9, 2021. 
 You asked the Plan to pay for a biopsy or excision of lymph nodes. You say that you have provided records to 
support the service billed. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 38510 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of a biopsy 
or excision of lymph nodes have not been met. Therefore, we decided that the Plan does not have to pay for a 
biopsy or excision of lymph nodes (38510) provided on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Covid-19 and respiratory panel-26 coded as 87651, 
87801 and 87798, 87640, 87634, 87631, 87681, 87541, 87502, 87486, U0004, U0005 provided December 22, 
2020 to January 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the 
billed service. 
 
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 the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee had symptoms of fever and cough. The records 
provided are insufficient to determine the medical necessity of the requested service. The record provided does 
not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the Covid-19 and respiratory panel-26 coded as 87651, 87801 and 87798, 87640, 
87634, 87631, 87681, 87541, 87502, 87486, U0004, U0005 provided December 22, 2020 to January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs to the group 4 power wheelchair (PWC). 
 
You asked the Plan to pre-approve the repairs. You say that you want your wheelchair to be repaired. The Plan 
denied your request. The Plan says repairs for Group 4 Power Wheelchair cannot be covered, because Group 4 
Power Wheelchairs have added capabilities that are not needed for use in the home and cannot be covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the repairs have not been met. The records show that repairs are 
requested for your power wheelchair. A Group 4 Power Wheelchair has features that do not serve a primary 
medical purpose. Medicare does not cover Group 4 Power Wheelchairs. Repairs for a Group 4 Power 
Wheelchair cannot be covered. Therefore, we decided that the Plan does not have to pre-approve repairs to the 
group 4 power wheelchair (PWC).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found there is no documentation that daily skilled 
services are required. You are walking household distances with a wheeled walker with contact guard to 
minimum assistance and is contact guard assist for transfers. Provided records do not document a significant 
decline in your functional status to necessitate daily inpatient skilled therapy services. Based on the medical 
records provided there is no documentation that you require the services on an inpatient basis, only in a skilled 
nursing facility setting. Records do not document the services in the home with home health care or in a long-
term care facility on a part time basis are not appropriate in this case. 
 
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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service January 7, 
2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
January 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve phototherapeutic keratectomy (PTK) (S0812) for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says this service is not valid 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 CPT code. 
 
Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This 
indicates that this code is not valid for Medicare purposes. 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 
pre-approve phototherapeutic keratectomy (PTK) (S0812) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81442, 81411, 81439, 81410, 81413, 81414, 
81161, 81286, 81256) provided November 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were 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 only the following codes should be billed for 
Cardiovascular Disease Screening: CPT code 80061 (Lipid panel) which includes CPT codes: 82465 
(Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) 
and/or 8447 (Triglycerides).  
 
We looked at the file and Medicare rules. The services billed are not eligible for coverage at cardiovascular risk 
testing. The codes billed are for screening purposes. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (81442, 81411, 81439, 81410, 81413, 81414, 81161, 81286, 81256) provided November 3, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve endovenous ablation therapy (36475). 
 
You asked the Plan to pre-approve Endovenous ablation therapy. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that invasive procedures will be considered medically 
reasonable and necessary if the patient meets the criteria as outlined, and the intervention is addressed and 
supported in the plan of care, for a 90 day episode of care, that includes a specific treatment plan determined by 
the assessment and evaluation of the lower extremity venous incompetence. 
 
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 Endovenous ablation therapy. Our 
reviewer says that this procedure is medically necessary. Our physician reviewer found the documentation 
supports that the procedure is medically reasonable and necessary for the enrollee in this case. The enrollee has 
VCSS scores of 8 bilaterally, C4 skin disease, and he has symptoms which interfere with daily activities. 
Physical examination showed multiple varicosities bilaterally, diffuse pigmentation over the lower third of both 
calves, and edema that extended above the bilateral ankles. Conservative therapy measures, including leg 
elevation and avoidance of prolonged sitting or standing, have not been successful. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Endovenous ablation therapy have been met. Therefore, we decided that the 
Plan has to pre-approve endovenous ablation therapy (36475).  
 
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 pay for lab services (G0463) provided August 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code G0463 is not supported in the medical record. Specifically, the CPT code was billed 
without a required modifier (25). Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
(G0463) provided August 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the omental flap (49905) provided on January 24, 2022. 
 
You asked the Plan to pay for the omental flap (49905). You say that the attached report states the actual 
procedure, and the doctor is willing to further explain the detail for the unpaid procedure. The Plan denied your 
request. The Plan says procedure code 43775 was approved, and procedure code 49905 is not supported by the 
medical records submitted. 
 
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 49905 is omental flap, intra-abdominal (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 omental flap (49905). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the documentation does not support mobilization of omental flap for reconstruction of a defect, as well as 
preparation of recipient site. The operative report does not include enough documentation to confirm this 
procedure has been performed per NCCI Policy Manual. 
 
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 omental flap (49905) have not been met. Therefore, we decided that the 
Plan does not have to pay for the omental flap (49905) provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect testing provided on January 13, 2021. 
 
You asked the Plan to pay for the CxBladder Detect testing. You say that this testing is supported by Medicare 
coverage rules and is medically necessary. The Plan denied your request. The Plan says this is an experimental 
test. 
 
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 the CxBladder Detect testing provided 
on January 13, 2021. have been met. No clinical record from the ordering physician were submitted. A 
determination on medical necessity cannot be made with only the order form and test results. Therefore, we 
decided that the Plan does not have to pay for the CxBladder Detect testing provided on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service April 9, 
2021. 
 
You asked the Plan to pay for procedure code 99291. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the medical records submitted do not support 
payment of this code. 
 
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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically the date of service at issue is 
April 9, 2021.  However, despite several requests from the Plan, you have only provided medical records 
applicable to dates of service March 31, 2021, to April 7, 2021.  You have provided no medical records to support payment of code 99291 billed for date of service April 9, 2021. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99291 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99291 billed for date of service April 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 6, 
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 January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation provided on January 4, 2022, 
billed with code 85060. 
 
You asked the Plan to pay for the blood smear interpretation as billed. You say that this was medically 
necessary and should be paid. The Plan denied your request. The Plan says this is not payable in the outpatient 
hospital setting. 
 
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 looked at the file and Medicare rules. CPT code 85060 has a Pro/Tech Flag of 8 in the Physician Fee 
Schedule. This means that this code is the professional component of clinical laboratory codes for which 
separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. No 
payment is recognized for CPT codes 88141, 85060 or HCPCS code P3001-26 furnished to hospital outpatients 
or non-hospital patients.  
 
The documentation supports that the enrollee was a hospital outpatient. Based on this information, we decided 
that Medicare rules for coverage of the blood smear interpretation as billed have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear interpretation provided on 
January 4, 2022, billed with code 85060.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045-26 billed for date of service January 
11, 2022. 
 You asked the Plan to pay for procedure code 71045-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 71045-26 is bundled into 
payment for code 36556. 
 
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 
71045-26 is a column II code to column I code 36556. 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 71045-26 billed for date of service 
January 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service January 9, 
2022. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70551. 
 
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 70544 
is a column II code to column I code 70551. 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 70544 billed for date of service January 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Oncology (urothelial), mRNA, gene expression profiling by 
real-time quantitative PCR of five genes (0013M) provided November 4, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you believe the evidence supporting the use of 
Cxbladder as a medically necessary diagnostic service is well established and affirmed by Medicare. The Plan 
denied your request. The Plan says this service does not meet Medicare's criteria of medically reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. This test has not been evaluated by the MolDx Programs technical 
assessment process and LCD L35396 cites it as noncovered. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of 
five genes (0013M) provided November 4, 2021.