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

 
We decided that the Plan does not have to pay for a debridement procedure (97597) billed for date of service 
March 24, 2022. 
 
You asked the Plan to pay for debridement. You say that you have provided medical records to support the 
service billed. The Plan denied your request. The Plan says rules for payment have not been met because the 
available records do not support the billed code. 
 
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 97597 is "Debridement (eg, high pressure waterjet 
with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, 
devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound 
assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) 
surface area; first 20 sq cm or less." 
 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 debridement. Our reviewer says that the service at issue does 
not meet criteria for payment. Our reviewer found that the available medical documentation does not support 
the use of procedure code 97597 based on the practices which the provider used for the active wound care. 
There was no anesthesia used nor was there any cutting devices used. There is a more appropriate procedure 
code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of debridement have not been met. Therefore, we decided that the Plan does not 
have to pay for a debridement procedure (97597) billed for date of service March 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 10, 2022, 
to March 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims must include a NOA. 
 
We looked at the file and Medicare rules. The file shows that the NOA was submitted with an incorrect 
admission date. 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 February 10, 2022, to March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain due to lumbar spondylosis.  He rates his pain a 7 out of 10 and describes the pain as sharp with radiation to both hips. He has been treated 
with medical therapy, ice, heat, and rest. There is no documentation that the enrollee has had a least two 
diagnostic medial branch blocks, with each one providing a consistent minimum of 80% sustained relief of 
primary pain. The review has determined that the records do not show that the requested radiofrequency 
ablation is indicated for the enrollee's condition. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation services.
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 
February 18, 2021, to March 13, 2021. 
 
You asked the Plan to pay for home health services. You say that you billed the claim correctly. The Plan 
denied your request. The Plan says you omitted to timely submit the RAP. 
 
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, the Plan has 
attested that you did not submit a RAP for the services at issue until December 16, 2021. Therefore, we decided 
that the Plan does not have to pay for the home health services provided to the enrollee from February 18, 
2021, to March 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on February 2, 2022. 
 
You asked the Plan to pay for the services provided. You say that the ordering physician determined the testing 
to be medically necessary. The Plan denied your request. The Plan says the services are included in payment to 
the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the pathology services were furnished to a hospital outpatient. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the pathology services provided on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic repetitive transcranial magnetic stimulation 
treatment (90867), subsequent delivery (90868), and therapeutic repetitive treatment with subsequent motor 
threshold (90869). 
 
You asked the Plan to pre-approve the physician services. You say that the symptoms listed on the denial are a 
misstatement. You say that the only reason you are experiencing these symptoms is as a result of the various 
medications which have been used to try to treat your severe depression. The Plan denied your request. The 
Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that repetitive transcranial magnetic stimulation (rTMS) is 
only considered medically necessary in adults who have a confirmed diagnosis of major depressive disorder 
(MDD), single or recurrent episode and the criteria 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 pre-approve the physician services. Our reviewer 
says that the requested services are not medically necessary. Our physician reviewer found the documentation 
does not indicate the specific medications you had been taking during the present episode of depression. The 
documentation does not indicate if the enrollee has undergone psychotherapy. The documentation does not 
indicate a history of electroconvulsive treatment (ECT) or transcranial magnetic stimulation (TMS). Therefore, 
the reviewer found that there is no indication the requested Transcranial Magnetic Stimulation (TMS) meets the 
criteria for coverage. 
 
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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve therapeutic repetitive transcranial magnetic stimulation treatment (90867), 
subsequent delivery (90868), and therapeutic repetitive treatment with subsequent motor threshold (90869).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 physical therapy visits. 
 
You asked the Plan to pre-approve therapy visits. You say that continuing therapy is medically necessary. The 
Plan denied your request. The Plan says that additional physical therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you are compliant is a home exercise program. The 
documentation does not support the need for professional therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy visits have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150, 87481, 87653, 87798, 87801, 87500, 
and 87641 billed for date of service October 27, 2021. 
 
You asked the Plan to pay for procedure code 87150, 87481, 87653, 87798, 87801, 87500, and 87641. You say 
that these services The Plan denied your request. The Plan says the services are not covered.  
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, there is no documentation of 
infectious agent detection by nucleic acid of multiple organisms by amplified probe(s) technique. 
 
We have confirmed that code 87150 is a column II code to column I code 87500. This claim has not been billed 
with an appropriate modifier to bypass the edit.  
 
We have confirmed that codes 87150, 87481, 87653, 87798, and 87641 are column II codes to column I code 
87801. 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 87150, 87481, 87653, 87798, 87801, 87500, and 87641 billed for date 
of service October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95867 billed for July 29, 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 are 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 CPT code. In this case, we have confirmed that code 95911 
is a column II code to column I code 95867 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 95867 billed for July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (0239U) provided 
October 26, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that FoundationOne Liquid CDx was ordered by 
the treating physician because the test results were needed to help determine the course of treatment of this 
enrollee. The Plan denied your request. The Plan says services do not meet Medicare NCD/LCD criteria 
 
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 0239U is targeted genomic sequence analysis panel, solid 
organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including 
substitutions, insertions, deletions, select rearrangements, and copy number variations. 
 
We find that CPT code 0239U is not supported in the medical record. Specifically, the claim was billed with a 
date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on 
October 12, 2021, rather than the billed date of service October 26, 2021. There is no documentation to support 
genetic testing on the billed date of service. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for targeted genomic sequence analysis panel (0239U) provided October 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 4, 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 the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that code 81455 is not supported in the medical record. Specifically, there is no documentation 
describing genetic testing on a sample collected on the date of service at issue. Therefore, we decided that the 
Plan does not have to pay for the laboratory services provided on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 22, 2022. 
 
You asked the Plan to pay for an 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 
services 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 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132, and 84295 billed for date of 
service September 7, 2021. 
 You asked the Plan to pay for procedure codes 82435, 84132, and 84295. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for codes 82435, 84132, and 84295 is bundled 
into payment for code 80051. 
 
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 82435, 
84132, and 84295 are column II codes to column I code 80051. 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 codes 82435, 84132, and 84295 
billed for date of service September 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Prostate Cancer Assay (81542) provided October 8, 
2021. 
 You asked the Plan to pay for the Prostate Cancer Assay. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that is considered reasonable and necessary to help 
identify men with localized Prostate Cancer and a life expectancy of at least 10 years who are good candidates 
for active surveillance. 
 
We looked at the file and Medicare rules. In this case we did not find that the medical records showed that the 
enrollee has a life expectancy of at least 10 years. Based on this information, we decided that Medicare rules 
for coverage of the Prostate Cancer Assay have not been met. Therefore, we decided that the Plan does not 
have to pay for the Prostate Cancer Assay (81542) provided October 8, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the cost-share for outpatient services provided on February 23, 2022, 
and May 4, 2022. 
 
You asked the Plan to waive the cost-share for outpatient services. You say that you have been having the same 
blood service for five years and never had a deductible. The Plan denied your request. The Plan says that the 
cost-share applied is correct. 
 
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 did not submit an Explanation of Benefits or claim information to 
support the allowed amount of the services billed. We also cannot confirm what services were billed on May 4, 
2022. This means that we cannot determine the cost you are being asked to pay is correct. Therefore, we 
decided that the Plan has to waive the cost-share for outpatient services provided on February 23, 2022, and 
May 4, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 64486 provided on February 22, 
2022. 
 
You asked the Plan to pay for the medical services coded 64486. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been 
billed as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 64486 
is a column II code to column I code 64488 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the medical services coded 64486 provided on February 22, 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 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician and nursing oversight in an IRF. While the enrollee may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says aquablation is not established as the standard of care for prostate glands of this patient's 
size per current literature. 
 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you do not meet the coverage criteria as cited above for this request. Specifically, the records show 
that the prostate gland is greater than 150 cc in size and a biopsy of the abnormal lesion on the magnetic 
resonance imaging (MRI) scan has not been done to rule out cancer.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transurethral waterjet ablation of the prostate.