Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service August 19, 
2022, to August 29, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 97010 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service August 19, 2022, to August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87486, 87498, 87502, 87541, 87581, 
87634, 87640, 87641, 87798 and 87801) provided on June 1, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says there is insufficient documentation to 
support the services billed. 
 
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 laboratory services have been met. 
Specifically, no test results were provided to support that these services were provided and were reported 
accurately. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87498, 
87502, 87541, 87581, 87634, 87640, 87641, 87798 and 87801) provided on June 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with codes 19307, 19303, and 
38900 for August 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis pointers were not billed correctly.  
The plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with an inappropriate 
diagnosis code for procedure laterality. 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 surgical 
services billed with codes 19307, 19303, and 38900 for August 24, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the physical therapy services rendered on February 11, 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 that the claim is a duplicate. 
 
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 states that the services at issue were previously paid on a separate 
claim; however, there is no documentation of a processed claim for these services. The Plan has not provided 
any documentation to support that the claim is a duplicate. Therefore, we decided that the Plan has to pay for 
the physical therapy services rendered on February 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing 87481, 87491, 87496, 87500, 87511, 
87529, 87532,87563, 87591, 87641,87651, 87653, 87661 and 87798 provided August 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you do not personally see the patients, you 
are dependent on receiving patient information from the ordering provider. The Plan denied your request. The 
Plan says the Plan does not have information needed to consider this charge. 
 
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 there was no specific clinical rationale for the requested laboratory testing. The 
review has determined that the items/services at issue in this case medically are not reasonable or 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the genetic testing 87481, 87491, 87496, 87500, 87511, 87529, 87532,87563, 87591, 
87641,87651, 87653, 87661 and 87798 provided August 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need therapy to get stronger and return to your 
previous baseline. The Plan denied your request. The Plan says your records do not show that you have 
ongoing medical issues which would require you to be seen 3 times per week by a rehabilitation doctor for 
evaluation of your medical goals and progress, medically necessary care may be provided safely in a different 
level of care. 
 
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 records do not support necessity for admission to an IRF due to lack of medical 
complexity with no acute rehabilitation nursing needs. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 4, 2022, to 
August 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment.  
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required TOB 
code. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
August 4, 2022, to August 17, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on August 31, 2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported as billed. 
The Plan denied your request. The Plan says that this service is not supported in the medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the record shows that 17 drug 
classes were tested in this case, including alcohol biomarkers, amphetamines, benzodiazepines, cannabinoids 
(natural), fentanyls, gabapentin (non-blood), methadone, methylenedioxyamphetamines, methylphenidate, 
opiates, opioids and opiate analogs, oxycodone, phencyclidine, pregabalin, skeletal muscle relaxants, 
tapentadol and tramadol. Based on this information, we decided that Medicare rules for coverage of drug 
testing have been met. Therefore, we decided that the Plan has to pay for definitive drug testing (G0482) 
provided on August 31, 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 pay for the home health services rendered on April 13, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims require distinct 5-position, 
alphanumeric home health HIPPS codes. 
 
We looked at the file and Medicare rules. The file shows that a valid HIPPS code was not billed on the claim. 
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 home health services rendered on April 13, 
2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 1, 2022, to June 
30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 1, 2022, to June 30, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genesight testing (81479) provided September 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please accept this appeal letter and the 
attached statement of medical necessity/test request form as your request for a retroactive authorization request. The Plan denied your request. The Plan says the enrollee did not meet the criteria for coverage of the Genesight 
testing to be determined to be 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 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 reviewed documentation indicates that the test was ordered for the diagnosis of 
anxiety disorder (ICD-10 code F41.1). Though the GeneSight Order Medical Necessity Documentation form 
stated that Sinequan (doxepin) and Paxil (paroxetine) were being considered for augmentation or 
starting/switching to, there is no documentation of such provided in the medical records sent for review. The 
LCD states, "The selection of the medications in question must be derived from clinical factors/necessity rather 
than from a pharmacogenetic test. Once the putative therapeutic agents are selected, and those agents are 
known to have gene-drug interactions as identified above, then a pharmacogenetic test may be considered 
reasonable and necessary when the result of that test is necessary for the physician's decision-making process 
regarding safely administering or dosing the drug. Pharmacogenetic testing is not considered reasonable and 
necessary merely on the basis of a patient having a particular diagnosis. In this case, there is no indication from 
the clinical record that the provider has already considered non- genetic factors to make a preliminary drug 
selection. The review has determined that the items/services at issue in this case are not medically reasonable 
or 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the Genesight testing (81479) provided September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95870 and 95938 billed for date of service 
June 20, 2022. 
 
You asked the Plan to pay for procedure codes 95870 and 95938. You say that this service was 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. In this case, we have confirmed that code 95870 
is a column II code to column I code 95861. This claim has not been billed with an appropriate modifier to 
bypass the edit. Code 95938 has an MUE of 1 unit. 1 unit was already billed and paid on September 2, 2022. 
An additional unit cannot be paid. 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 codes 95870 and 95938 billed for date 
of service June 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a barium swallow study and diagnostic radiology services 
provided on September 8, 2022. 
 
You asked the Plan to pay for the barium swallow study and diagnostic radiology services. You say that  The 
Plan denied your request. The Plan says the documentation supports the studies performed at a nursing home 
(via mobile van/portable x-ray) denied as an excluded place of service. 
 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 barium swallow study and diagnostic radiology services have not been met. Therefore, we 
decided that the Plan does not have to pay for a barium swallow study and diagnostic radiology services 
provided on September 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 10, 2022, to April 13, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the removal of the diagnosis codes and change in DRG is based on lack of supporting clinical evidence from the medical record provided and not based solely 
on coding guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 190. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee has chronic obstructive pulmonary disease (COPD) on home oxygen (2L) who was admitted 
to the hospital with COPD exacerbation. She was treated with her baseline 2L oxygen supplementation rate 
with normal/stable pulse oximetry readings during the hospital stay. She did not require any vent or BiPAP 
support (although used CPAP for sleep apnea at baseline) and didn't require or use high flow oxygen support to 
meet the definition of acute respiratory failure. Therefore, the diagnosis of acute respiratory failure with 
hypoxia or hypercapnea each is not sufficiently supported in the provided documentation for this hospital stay.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from April 10, 2022, to April 13, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service May 22, 
2022. 
 
You asked the Plan to pay for procedure code 36000. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 36000 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service May 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intra-abdominal omental flap provided to the enrollee on 
June 2, 2021. 
 
You asked the Plan to pay for the flap. 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 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 flap. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that in this case, the record indicates that 
the enrollee underwent an operative procedure.  The record is insufficient to establish that the omentum 
was fully mobilized and pedicled on the right or left gastroepiploic vessel and that the requirements of the 
requested code are satisfied. 
 
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 flap have not been met. Therefore, we decided that the Plan does not have to 
pay for an intra-abdominal omental flap provided to the enrollee on June 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
supply allowance (A4595) provided July 1, 2022 
 
You asked the Plan to pay for the TENS supply allowance. You say that according to the prescription, the 
prescribing physician recommends an extended lifetime use of equipment as they are diagnosed with chronic 
pain and compromised mobility without the option for surgical correction. The Plan denied your request. The 
Plan says the billed supply code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, per USPS.GOV, the package shows not delivered 
and the proof of delivery is not itemized to indicate the specific supplies. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the transcutaneous electrical nerve stimulation (TENS) supply allowance (A4595) 
provided July 1, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate (conscious) sedation services (code 99152) 
provided on August 10, 2022. 
 
You asked the Plan to pay for moderate (conscious) sedation services. The Plan denied your request. The Plan 
says the documentation submitted did not indicate the presence of an independent trained observer to assist in 
the monitoring of the patient's level of consciousness and physiological status; therefore, the billed service 
cannot be verified. 
 
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 moderate (conscious) sedation services 
have been met. Therefore, we decided that the Plan does not have to pay for moderate (conscious) sedation 
services (code 99152) provided on August 10, 2022.