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

 
We decided that the Plan does not have to pay for outpatient hospital services provided on September 27, 2021. 
 
You asked the Plan to pay for outpatient hospital services. You say that this claim was billed correctly, and 
these services are supported in the records. The Plan denied your request. The Plan says this claim has one or 
more Integrated Outpatient Code Editor (I/OCE) edit errors, and this claim cannot be paid until this information 
is corrected. 
 
The Plan must follow Medicare rules. Medicare rules say that code G0463 has a Status Indicator of V, which 
means that this code is an Evaluation and Management (E&M) code used to report a medical visit that takes 
place on the same date that a procedure with status indicator S or T is performed, but that is significant and 
separately identifiable from the procedure. The rules say that when and E&M code is on the same day as a type 
T or S procedure does not have a modifier of 25, then edit 21 applies and the claim is returned to the 
provider for correction. 
 
The rules also say that services identified as information only service(s) are non-covered and will not be 
paid.  
 
We reviewed the I/OCE Specifications file for this date of service. OCE edit 21 is invoked when One or more 
type T or S procedures occur on the same day as a line item containing an E&M code, without modifier 25. 
G0463 is an E&M code which, in this case, was billed with 71260, which has a status indicator of S. Modifier 
25 was not billed with this service. Therefore, edit 21 applies and this claim is rejected to be returned to the 
provider for correction. 
 
In addition, code G1004 is an information only code and is not eligible for Medicare payment. Based on this 
information, we decided that Medicare rules for coverage of outpatient hospital services have not been met. 
Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on 
September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you have reviewed the in-network oral surgeons 
and none of them have the level of expertise and experience that the out-of-network provider has to offer. The 
Plan denied your request. The Plan says the provider is out-of-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the office visit. We found no exception that would require the Plan to pre-approve 
the office visit. Therefore, we decided that the Plan does not have to pre-approve office visit to be provided by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81225, 81226, 81227, 81230, 
81231, 81291, 81479, 0032U, and 0033U provided on July 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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 81225, 81226, 81227, 81230, 81231, 81291, 81479, 0032U, and 0033U are not 
supported in the medical record. Specifically, if a laboratory procedure produces multiple reportable test 
results, only a single CPT code shall be reported for the procedure. If there is no CPT code that describes the 
procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service. 
Review of the file shows that more than a single procedural code was billed for the services rendered. 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 laboratory services coded 81225, 81226, 
81227, 81230, 81231, 81291, 81479, 0032U, and 0033U provided on July 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. You say that the enrollee clearly exceeds the CMS established defining criteria for a medically 
appropriate LTACH admission. The Plan denied your request. The Plan says the guidelines for coverage of 
LTACH care have not been met. The Plan says that the enrollee's needs may be met in the current hospital 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with acute on chronic hypoxic respiratory failure in the 
setting of chronic obstructive pulmonary disease exacerbation. The record indicates that the enrollee still 
requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute 
care services, and these have not been denied. The medical record does not indicate that the enrollee requires 
services that he is not currently receiving but that would be available at the LTACH facility.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 23, 2022. 
 
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 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 the laboratory services provided on February 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mammogram to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the mammogram. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a mammogram to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 3, 2021. 
 
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. This means that profession 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 August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 31, 
2021. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed.  
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not contain 
documentation to support 22 or more drug classes. Based on this information, we decided that Medicare rules 
for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded G0483 provided on December 31, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
February 3, 2022, to March 4, 2022. 
 You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not receive daily skilled services. 
 
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 pay for the SNF care. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from February 3, 2022, to March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the plan to reconsider their 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 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 October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 22, 2021. 
 
You asked the Plan to pay for the lab services. 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 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 the lab services provided on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit services provided on January 31, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home visit services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 home visit services provided on January 31, 2022 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation services provided on 
November 3, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the interrogation device evaluation services. You say that you would like the 
plan to reconsider their decision. The Plan denied your request. The Plan says the services billed require prior 
authorization. 
 
 
 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 the interrogation device evaluation services 
provided on November 3, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the IsoPSA Assay rendered on July 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 services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular pathology is covered when specific 
criteria are 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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee had elevated prostate specific 
antigen (PSA). It is documented in the urology note that the enrollee has not had a prostate biopsy or magnetic 
resonance imaging (MRI). While the IsoPSA Assay has secured breakthrough device designation from the 
Food and Drug Administration (FDA), there is insufficient evidence that this is a clinically valid test, based on 
published peer reviewed medical literature with analytical validity and clinical utility at this time. Available 
studies have not assessed IsoPSA's effect on patient management, and IsoPSA's impact on patient outcomes has 
not been sufficiently demonstrated. 
 
We looked at this physician's review, the file, and Medicare rules. 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 IsoPSA Assay rendered on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on July 12, 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 services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular pathology is covered when specific 
criteria are 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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of malignant 
neopasm of the appendix. The documentation does not support that alternative laboratory or clinical tests to 
definitively diagnose the disorder/identify the condition are unavailable or results are clearly equivocal, and 
that the results of the testing would directly impact treatment or management of the Medicare beneficiary, and 
that the enrollee has not previously received genetic testing for the disease/condition. The testing was therefore 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the FoundationOne CDx testing rendered on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing coded 
as 81161, 81286, 81410, 81411, 81413, 81414 and 81479 provided November 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting a re-determination of the 
denial and have enclosed documentation to substantiate the claim. The Plan denied your request. The Plan says 
services do not meet coverage requirements. 
 
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 records show that the Plan made multiple outreach attempts to 
verify if the doctor indicated on the order, wrote the order for the enrollee to undergo cardiovascular genetic 
testing. 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 cardiac risk assessment genetic 
screening testing coded as 81161, 81286, 81410, 81411, 81413, 81414 and 81479 provided November 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 29, 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 August 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 19, 2022 by an 
out-of-network (OON) provider. 
 
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 rendered by an out-of-network provider without prior authorization. 
 
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 the laboratory services provided on January 19, 
2022 by an out-of-network (OON) provider.