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

 
We decided that the Plan does not have to pay for the home health services rendered from September 11, 2021, 
to October 9, 2021 and from February 8, 2022, to March 8, 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 HH PPS claims must report a 0023 revenue code line 
on which the first four positions of the HIPPS code match the code submitted on the RAP. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the correct 
revenue code. 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 from September 
11, 2021, to October 9, 2021 and from February 8, 2022, to March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service March 21, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99140 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99140 billed for date of 
service March 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health physical therapy services (CPT code 
G0151 x6). 
 
You asked the Plan to pre-approve the home health physical therapy services. You say that the services are 
necessary. The Plan denied your request. The Plan says the medical record does not document a clearly evident 
need for the services of a skilled physical therapist. The Plan states the enrollee has already been educated on a 
home exercise program and there is no documentation of an active or acute on chronic condition that would 
necessitate a new program. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health physical therapy 
services. Our physician reviewer found the records do not support that the complexity of the enrollees 
conditions are such that the skills of a professional therapist are required to achieve further improvement in the 
enrollee's symptoms or functional status. Further utilization of the home exercise program appears appropriate 
at this point. 
 
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 home health physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the home health physical therapy services (CPT code G0151 
x6).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says 
that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on February 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 20, 2021, billed 
with codes 81401, 81403, 81404, 81405, 81406, 81407, 81408 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says this type of hereditary 
assessment is not covered by Medicare. In addition, the performance of multiple molecular tests, regardless of 
whether the requisition lists the tests as a panel or individually, should be billed under a single code to prevent 
stacking of codes. The proprietary lab is requesting coverage of a comprehensive panel by stacking codes. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 20, 2021, billed with codes 81401, 81403, 81404, 81405, 81406, 81407, 81408 and 81479.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided by a Registered Nurse 
First Assistant (RNFA) on January 3, 2022. 
 
You asked the Plan to pay for the RNFA services. You say that this was the only surgical assistant available, so 
this should be covered. The Plan denied your request. The Plan says this is not provider type that can be paid 
by Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
by a Registered Nurse First Assistant (RNFA) on January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 17, 2022 billed with 
codes 81225, 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 17, 2022 billed with codes 81225, 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, 
0032U, and 0033U.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 2, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on February 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 the 
services are not medically necessary. Our physician reviewer found 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 those services in the assisted living facility 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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prostate artery embolization. 
 
You asked the Plan to pre-approve prostate artery embolization. You say that the requested procedure is 
medically necessary and supported by the documentation provided. You say that the requested procedure is a 
safe, effective, minimally invasive treatment with similar efficacy of traditional prostate surgery with quicker 
recovery and fewer complications. The Plan denied your request. The Plan says literature does not support the 
need for this service. The Plan says that more studies are needed to show it can help the enrollee's condition. 
The Plan says that the enrollee's condition can be managed by other procedures. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve prostate artery embolization. Our 
reviewer says that prostate artery embolization is not considered medically reasonable and necessary in this 
case. Our physician reviewer found prostatic arterial embolization (PAE) is considered an experimental 
technique to treat symptomatic benign prostatic hyperplasia (BPH.) Very limited studies have demonstrated 
possible short-term safety and efficacy.   
 The most recent American Urological Association (AUA) guidelines do not recommend this procedure outside 
of a clinical trial setting due to the heterogeneity in the available literature and safety concerns regarding 
radiation exposure, postembolization syndrome, vascular access, technical feasibility, higher clinical failure 
rate compared with more traditional methods (eg, transurethral resection of the prostate [TURP]). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve prostate artery embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on July 2, 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 Current Procedural Terminology (CPT) code 64447-59-RT 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. 
 
In this case, the CPT Code Manual definition of code 64447 is "Injection(s), anesthetic agent(s) and/or steroid; 
femoral nerve." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the anesthesiology 
records/photocopies submitted are mostly illegible due to hand-writing and poor copy quality. Due to the poor 
quality/illegible anesthesia records, along with the lack of a submitted procedure note to assess certain requirements for CPT 64445-59-RT, the postoperative pain management provided by the anesthesiologist, 
cannot be verified. In addition, the submitted documentation does not indicate that the right femoral nerve 
block was performed at the surgeon's request and that it was performed for post-operative pain management. 
The review has determined that the documentation did not support that billing code CPT 64447-59-RT (right 
femoral nerve block) should be reimbursed. 
 
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 anesthesia services provided to the enrollee on July 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA), gastrointestinal pathogen (87507) provided March 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you went to the emergency room and opted 
to go home instead of being admitted. At your release they wanted ore lab tests, which you could do at home. 
The Plan denied your request. The Plan says service is not covered by Medicare. 
 
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. The claim was billed with code R19.7, which per the LCD is not a 
covered diagnosis code. 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 infectious agent detection by nucleic 
acid (DNA or RNA), gastrointestinal pathogen (87507) provided March 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for plastic surgery services provided to the enrollee on October 
1, 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 denied codes are not supported in the 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 the denied codes is: 
 
CPT 14302: 
 
Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately 
in addition to code for primary procedure) 
 
CPT 15002: 
 
Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including 
subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body 
area of infants and children  
CPT 15003: 
 
Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including 
subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or 
part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for 
primary procedure) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report did not 
sufficiently document the adjacent tissue transfer or rearrangement of any area for each additional 30.0 sq cm, 
or part thereof. CPT 14302 cannot be verified as rendered in this case. The operative report did not include 
sufficient documentation of a surgical preparation or creation of recipient site by excision of open wounds, 
burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; 
each additional 100sq cm, or part thereof. CPT 15003 cannot be verified as rendered in this case. The operative 
note does not support that CPT code 15002 was separate and independent from CPT 14301 - adjacent tissue 
transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. 
 
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 plastic surgery services provided to the enrollee on October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visit you had with a naturopathic doctor on January 31, 
2022. 
 
You asked the Plan to pay for the naturopathy visit. You say that naturopathy is the primary form of alternative 
medicine and your contract covers alternative medicine. The Plan denied your request. The Plan says services 
with a naturopath are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. 
Although your Plan has an Alternative Medicine supplemental benefit, your contract explicitly excludes 
coverage for naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we 
decided that the Plan does not have to pay for the visit you had with a naturopathic doctor on January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 4, 2021, billed with 
codes 81402, 81401x2, 81400, 81321, 81314, 81311, 81310, 81309, 81301, 81276, 81275, 81272, 81270, 
81235, 81210, 81173, 81121 and 81120. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services are covered by Medicare 
and are medically necessary. The Plan denied your request. The Plan says the enrollee meets the criteria for 
medical necessity; however, per Medicare rules, the testing in this case should be billed with only code 81479. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 4, 2021, billed with codes 81402, 81401x2, 81400, 81321, 81314, 81311, 81310, 81309, 81301, 81276, 
81275, 81272, 81270, 81235, 81210, 81173, 81121 and 81120.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 14, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says that the Plan has to 
pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and 
pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services.  
 
 
 
  
 
 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 14, 2022.