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

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis (0242U) provided on 
July 23, 2021. 
 
You asked the Plan to pay for a targeted genomic sequence analysis. You say that the services at issue were a 
necessity for the enrollee's care. 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 providers/suppliers must report services 
correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a targeted genomic sequence analysis have not been met. Specifically, this claim was billed with 
the laboratory place of service code while the records indicate that the enrollees face-to-face service was 
rendered in an office setting. There is a more appropriate place of service code for the services billed. 
Therefore, we decided that the Plan does not have to pay for a targeted genomic sequence analysis (0242U) 
provided on July 23, 2021.
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 member needs rehabilitation because the 
member does have an acute injury. You state that the member needs physical therapy and occupational therapy 
to become able to adjust to life outside of the facility and there is not a Medicare guideline that states that the 
member does not need multiple injuries to be approved for SNF. The Plan denied your request. The Plan says 
the stay is not medically necessary. 
 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 the member has stabilized medically and is 
ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy 
services on a daily basis. The member is medically stable and can receive further rehabilitation services at a 
lower level of care. Although further rehabilitation services would be appropriate to improve function, as a 
practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The 
member does not have any parental medication; complex wound care or nutrition given via a feeding tube. The 
member is medically stable without any acute exacerbations of chronic medical problems. The member's 
physical function is at or near their baseline and they can receive services at a lower level of care. Admission to 
a SNF for inpatient skilled rehabilitation services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 review has determined that the complexity of the patients nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on January 8, 
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 an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, 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 imaging services provided to the enrollee on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 22, 
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 Healthcare Common Procedure Coding System (HCPCS) code G0483-90 (1 Unit) 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. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a 
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's 
office (POS 11). 
 
 
 
  
 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 drug testing services provided to the enrollee on 
February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Athena Ataxia Comprehensive genetic testing panel 
provided on July 20, 2021, billed with multiple individual gene codes. 
 
You asked the Plan to pay for the Ataxia Comprehensive panel. You say that this testing is necessary to 
provide information to aid in the treatment of the enrollee's condition. The Plan denied your request. The Plan 
says this is not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that it is incorrect coding to use individual gene codes 
for a testing panel of genes. There are specific codes to be used when testing for a genetic analysis of a panel of 
genes. 
 
In this case, the rendered testing is considered a panel and was not billed using a single panel code. Therefore, we decided that the Plan does not have to pay for the Athena Ataxia Comprehensive genetic testing panel 
provided on July 20, 2021, billed with multiple individual gene codes.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 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 provider did not bill as required by 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 CPT code. In this case, we have confirmed that code 74176 
is a column II code to column I code 74177. 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 imaging services provided to the enrollee on October 12, 2021.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the cytopathology billed with CPT code 88173. We decided that the 
Plan does not have to pay for the cytopathology billed with CPT code 88172.  
 
You asked the Plan to pay for the cytopathology billed with CPT code 88173. You say that you would like 
reconsideration based on the records submitted. The Plan says that an edit exists between CPT codes 88172 and 
88104. 
 
We decided that the Plan has to pay for the cytopathology billed with CPT code 88173.  
 
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the Independent Review Entity (IRE). 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that the 
Plan has not made diligent efforts to gather and forward sufficient information. Specifically, the Plan has not 
forwarded any evidence as to why the cytopathology service billed with CPT code 88173 has been denied. It is 
the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the 
cytopathology billed with CPT code 88173.  
 
We also decided that the Plan does not have to pay for the cytopathology billed with CPT code 88172. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage of the cytopathology services billed with CPT code 88172 have not been met. 
Specifically, an edit exists between CPT code 88172 and 88104. CPT code 88172 has not been billed with an 
appropriate modifier to bypass this edit and is not separately reimbursable. Therefore, we decided that the Plan 
does not have to pay for the cytopathology billed with CPT code 88172. 
 
 
 
 
 
  
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: Favorable

 
We decided that the Plan has to pay for debridement services (procedure code 11000 and 11001) provided to 
the enrollee on August 17, 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 that the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 11000: 
 
Debridement of extensive eczematous or infected skin; up to 10% of body surface 
 
CPT 11001: 
 
Debridement of extensive eczematous or infected skin; each additional 10% of the body surface, or part thereof 
(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 the enrollee had a diagnosis of rash and 
other non-specific skin eruption on her back. She had two procedures: wound #1 - upper back - surgical 
debridement with a total area of 100 sq cm, and wound #2 lower back - surgical debridement with a total area 
of 25 sq cm. The records support the coding of CPT 11000, and CPT 11001. The records support that CPT 
11000 was separately identifiable and distinct. 
 
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 
debridement services (procedure code 11000 and 11001) provided to the enrollee on August 17, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelegy Ellipta. 
 
You asked the Plan to pre-approve Trelegy Ellipta. You say that this drug is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 
medical benefit. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trelegy Ellipta.  
 
Benefits for Trelegy Ellipta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 17, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 8, 2021, 
and April 9, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
due to the missing records for these dates, medical necessity cannot be determined, nor can we research what 
services were rendered on these dates. 
 
The Plan must follow Medicare rules. Medicare rules say 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. The file shows that you did not submit sufficient medical documents 
to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for subsequent 
nursing facility care provided on April 8, 2021, and April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a procedure to remove a tumor (21932) 
provided on October 1, 2021, at an outpatient hospital facility. 
 
You asked the Plan to waive the copayment for a tumor removal. You say that you are dissatisfied with the care 
you received. The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for each Medicare-covered visit to an outpatient hospital facility.  
 
 
 
 You have been asked to pay a $300 copayment for a tumor removal. A tumor removal falls within the 
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers" benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Health plans are not required to waive this cost sharing when there is dissatisfaction with the quality of 
care received. Therefore, we decided that the Plan does not have to waive the copayment for a procedure to 
remove a tumor (21932) provided on October 1, 2021, at an outpatient hospital facility.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the clinical information provided supports the 
need for SNF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. 
The Plan says that the enrollee can receive the care needed in another setting. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are 
not shown to be required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees care needs appear to be custodial and can, as a practical matter, be provided at a lower 
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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology services provided to the enrollee on April 
13, 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 do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is:  
 
CPT 95885: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary 
procedure) 
 
 CPT 95909: 
 
Nerve conduction studies; 5-6 studies 
 
CPT 95955: 
 
Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). 
 
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 the enrollee is an 88-year-old woman 
with unstable fractures of the C1-C2 complex, who underwent intraoperative neurophysiological monitoring 
during odontoid screw placement and C1 and C2 fusion surgery. The documentation does not support the 
performance of nerve conduction, amplitude, and latency/velocity study during the surgery. The documentation 
does not support the performance of Nerve conduction studies; 5-6 studies. The documentation is insufficient 
to support CPT 95955. 
 
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 neurophysiology services provided to the enrollee on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
 The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services provided on July 7, 2021.