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

 
We decided that the Plan does not have to pay for laboratory services (87641, 87798, 88305, 88312) provided 
on March 9, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the services at issue were not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare will cover molecular syndromic infectious 
disease pathogen identification panel tests when the criteria listed in the Medicare rules section of this letter 
have been met. 
 
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 laboratory services. Our reviewer says that 
the services at issue were not medically reasonable and necessary in this case. Our physician reviewer found 
that the enrollee was suffering with painful onychomycosis to bilateral hallux toenails. A diagnosis of 
onychomycosis had been made already and is included in the progress notes. It appears that the biopsy of the 
hallux toenails as well as the testing at issue exceeds what may be considered standard of care for the diagnosis 
of onychomycosis of toenails. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services (87641, 87798, 88305, 88312) provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88341, 88342, 88360, 88365, 88381) provided 
on January 4, 2022. 
 
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 codes 88341, 88342, 88360, 88365 and 88381 are not supported in the medical record. 
Specifically, the services billed have a professional component / technical component of 1. The patient was an 
inpatient when the services were provided. The interpretation must be separately billed by the physician with 
modifier 26. 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 (88341, 88342, 88360, 
88365, 88381) provided on January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87801) provided on April 25, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 We looked at the file and Medicare rules. The panel in question was billed with multiple codes, not one unit of 
one code as required by Medicare rules. 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 
laboratory services (87801) provided on April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 8, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
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 laboratory services provided on February 8, 2022, have been met. The file shows that Plan made multiple attempts to obtain medical records 
with no response. Therefore, we decided that the Plan does not have to pay for the laboratory services provided 
on February 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted for pleural effusion. Medical problems are stable. 
 
 There are no complex nursing or rehabilitation needs. While the enrollee has a need for physical or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Medically 
necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an attended polysomnography (95810). 
 
You asked the Plan to pre-approve an attended polysomnography. You say that the enrollee should qualify for 
sleep testing and meets medical necessity. The Plan denied your request. The Plan says that the enrollee does 
not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that a Type I PSG is covered when used to aid the 
diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed 
attended in a sleep lab facility. 
 
 
  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 an attended polysomnography. Our 
reviewer says that attended diagnostic polysomnography (95810) is reasonable and medically necessary. Our 
physician reviewer found this enrollee has symptoms suggestive of both obstructive and central sleep apnea. 
Our reviewer found that the enrollee also has sleep vocalization and leg movements, raising questions of sleep 
disorders not well diagnosed with a home study. Our physician reviewer also found that in addition, chronic 
pain, bipolar disorder, and cognitive issues may make a home study impractical. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an attended polysomnography have been met. Therefore, we decided that the 
Plan has to pre-approve an attended polysomnography (95810).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 14, 2022. 
 
You asked the Plan to pay for the lab 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 the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, when billed with a facility place of service, the 
professional interpretation must be billed with modifier -26 for payment to be considered. 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 the lab services provided on March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 4, 2021. 
 
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 March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation rendered on January 31, 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 procedure code 99442 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99442 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion. 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, the file shows that an office 
visit was billed within seven days of the telephone evaluation services on January 31, 2022. 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 telephone evaluation rendered on January 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on January 27, 2022. 
 
You asked the Plan to pay for ambulance transport. You say that the enrollee had COVID and couldn't use 
other transportation. The Plan denied your request. The Plan says this was not necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for ambulance transport. Our reviewer says that 
the requirements for coverage of ambulance services have not been met. Our physician reviewer found based 
on the medical records provided, there is no documentation that other means of transport were contraindicated 
for the enrollee. The records do not document any symptoms related to COVID infection, and the enrollee was 
outside the Centers for Disease Control and Prevention isolation window. The records do not document the 
enrollee was non-weight bearing on the right hip that had been previously fractured. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance transport provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90636 billed for date of service March 4, 
2022. 
 
You asked the Plan to pay for procedure code 90636. You say that you disagree with the denial. 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 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 90636 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 
procedure code 90636 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 90636 billed for date of service March 4, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve MBBs at 2 levels. We decided that the Plan does not have to pre-
approve an MBB at a third level.  
 
You asked the Plan to pre-approve cervical spine medial branch blocks (MBB) at 3 levels. You say that the 
enrollee tried to get these injections last year. You say that they were unable to. You also say that the enrollee 
is now able to receive these injections. The Plan denied your request. The Plan says the injections are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
 We decided that the Plan has to pre-approve MBBs at 2 levels.  
 
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 MBBs. Our reviewer says that 2 
medial branch blocks are medically necessary. Our physician reviewer found the coverage guidelines limit 2 
levels per session. Therefore, the reviewer found that 2 medial branch block levels are 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 the MBBs have been met. Therefore, we decided that the Plan has to pre-
approve MBBs at 2 levels.  
 
We also decided that the Plan does not have to pre-approve a MBB at a third level. 
 
Our reviewer also says that a third medial branch block is not medically necessary. The reviewer found that a 
MBB at a third level in one session exceeds the coverage guidelines. Therefore, the reviewer found that a MBB 
at a third level 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 the MBBs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a MBB at a third level. 
 
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 procedure code 96450 billed for date of service December 
13, 2021. 
 
You asked the Plan to pay for procedure code 96450. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 96450 is bundled into 
payment for code 99232. 
 
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 96450 
is a column II code to column I code 99232. 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 96450 billed for date of service December 13, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service January 26, 
2022. 
 You asked the Plan to pay for procedure code 88321. You say that you disagree with the denial. 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 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 88321 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 
procedure code 88321 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88321 billed for date of service January 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
November 18, 2020, to December 17, 2020. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, no clinical 
notes for the billed skilled nursing dates of service were provided. This means that the documentation does not 
support the billed visits. Therefore, we decided that the Plan does not have to pay for the home health services 
provided to the enrollee from November 18, 2020, to December 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Respiratory assist device (E0471) provided on April 26, 
2022. 
 
You asked the Plan to pay for procedure code E0471. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the item is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the case file and Medicare rules. Medicare says that a bi-level positive airway pressure device 
with back-up rate coded as E0471 is not reasonable and necessary if the primary diagnosis is obstructive sleep 
apnea (OSA). In this case, the file shows that the primary diagnosis billed with code E0471 is for OSA. 
Therefore, we decided that the Plan does not have to pay for the Respiratory assist device (E0471) provided on 
April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the facility services provided from March 31, 2022, through April 5, 
2022. 
 
You asked the Plan to pay for the facility services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that authorization was not requested for the services at issue. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. The enrollee was found to 
have potential sepsis in the emergency department. This would lead a prudent layperson to believe immediate 
care is necessary to prevent harm. A prudent layperson with an average knowledge of medicine would 
reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. 
Therefore, we decided that the Plan has to pay for the facility services provided from March 31, 2022, through 
April 5, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty extra-wide hospital bed. 
 
You asked the Plan to pre-approve a heavy duty extra-wide hospital bed. You say that this is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the enrollee does not satisfy 
the coverage criteria for the requested heavy duty extra-wide hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra-wide hospital bed (E0301, 
E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the 
beneficiary's weight is more than 350 pounds but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. In this case, the enrollees weight is 250 pounds which is not more 
than the 350-pound requirement. Based on this information, we decided that Medicare rules for coverage of a 
heavy duty extra-wide hospital bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a heavy duty extra-wide hospital bed.