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

 
We decided that the Plan does not have to pay for the genetic testing provided on September 15, 2022, billed 
with codes 81225 and 81226. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 
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 
September 15, 2022, billed with codes 81225 and 81226.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81479 provided on May 31, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 81479 is unlisted molecular pathology procedure. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, no medical records were 
provided to support this code. The documentation supports code 81162 (BRCA1 and BRCA2 testing), and this 
code was already processed and paid by the Plan. Code 81479 is not payable as billed.. 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 81479 provided on 
May 31, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management (EM) services provided on July 6, 
2022, billed with code 99308. 
 
You asked the Plan to pay for the EM services. You say that this claim should be paid. The Plan denied your 
request. The Plan says that 99308 was billed on the same date as 90834. As such, a modifier is needed with 
99308. 
 
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 has indicated that since the code 99308 is a Column 2 code in relation 
to code 90834 that a modifier must be used to allow payment for 99308. However, the edit should not be 
applied to these two codes, as the services were rendered by providers of two different specialties. The 99308 
code was provided by a nurse practitioner, while 90834 by a psychologist. As such, no modifier is needed to 
allow payment for both codes. Therefore, we decided that the Plan has to pay for the evaluation and 
management (EM) services provided on July 6, 2022, billed with code 99308.  
 
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 initial preventive physical examination (IPPE) billed with 
code G0402 for date of service July 20, 2022. 
 
You asked the Plan to pay for the IPPE. You say that this code was billed correctly. The Plan denied your 
request. The Plan says the patient was ineligible for an IPPE on the date of service in question. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare only covers one IPPE per beneficiary 
in their lifetime. Beneficiaries are eligible for this service for 1 year after their Medicare Part B coverage 
effective date. In this case, the enrollee's Medicare Part B effective date was June 1, 2021.  IPPEs are only 
covered within 12 months of this effective date.  The IPPE service in question was provided beyond this 12-
month window.  As a result, the IPPE service is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the IPPE have not been met. Therefore, we decided that the Plan does not have to pay for the initial 
preventive physical examination (IPPE) billed with code G0402 for date of service July 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve C5-6 posterior cervical laminectomy and screw fixation. 
 
You asked the Plan to pre-approve the services. You say that there is no conservative treatment available for 
the enrollee's condition. The Plan denied your request. The Plan says there is no documentation submitted that 
indicates other sources of pain have been ruled out. 
 
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 there is no documentation of any six-week trial of physical therapy. More conservative measures are 
needed. 
 
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 C5-6 posterior cervical laminectomy and screw fixation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95885 billed for date of service March 7, 
2022. 
 
You asked the Plan to pay for procedure code 95885. The Plan denied your request. The Plan says payment for 
code 95885 is bundled into payment for code 95860. 
 
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 95885 
is a column II code to column I code 95860 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 95885 billed for date of service March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services rendered on September 6, 
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 claim was 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 not billed with an appropriate 
primary diagnosis 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 surgical pathology 
services rendered on September 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88305, 88312, 88313) provided on July 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are supported in the medical record. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (88305, 88312, 88313) provided on July 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 a Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Vertiflex device is experimental. More research is needed to demonstrate its 
safety and effectiveness. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you have been going to the provider and 
paying out of pocket. You say that they are the only place close to you and you want to continue receiving the 
care from that specific provider office. The Plan denied your request. The Plan says the services are available 
within the 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 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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 99285. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99285 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99285 billed for date of service September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 11, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
10, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed properly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services billed with code 99285 for 
June 6, 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 code 99285 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that pre-operative services are included in the global 
surgical package.  
 
We looked at the file and Medicare rules. Procedure code 99285 was related to billed on the same day as minor 
surgical procedure 49083. Payment for code 99285 is included in the global surgical package for code 49083. 
Therefore, we decided that the Plan does not have to pay for the emergency room services billed with code 
99285 for June 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abecma CAR-T cell therapy. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says Abecma, as requested, is not FDA-approved, nor compendia-listed for the patient's 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
As Abecma is not FDA-approved, this requested therapy would not be considered medically reasonable and 
necessary. 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 Abecma CAR-T cell therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided on July 25, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgery 
services are not covered for this code. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 13160. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon 
services provided on July 25, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrical stimulator supplies provided on July 27, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that this claim should be paid. The 
Plan denied your request. The Plan says that there is no signed order or itemized delivery ticket. There is also 
no evidence this was received by the enrollee. 
 
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's denial rationale is not supported. The packing slip is itemized and is 
linked to the delivery confirmation with the tracking number, and the delivery confirmation shows that the 
package was delivered. There is also a signed order in the file. Therefore, we decided that the Plan has to pay 
for the electrical stimulator supplies provided on July 27, 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 procedure codes 99220 and 99497 billed for date of service 
January 10, 2022. 
 
You asked the Plan to pay for procedure codes 99220 and 99497. The Plan denied your request. The Plan says 
the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT codes 99220 and 99497 is 1. The MAI value for this code is 2. You billed 2 
units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 99220 and 99497 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99220 and 99497 billed for date of service January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental pneumatic appliance 
for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that the requested 
device and appliances are medically necessary. The Plan denied your request. The Plan says this special pump 
can be approved when the enrollee's leg swelling is severe and long-standing, and all criteria is met. The 
enrollee must have lymphedema extending into the chest, trunk, and/or abdomen and the member must have 
failed a four-week trial of a basic compression pump (E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652), a segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 12, 2021. 
 
You asked the Plan to pay for the office visit. You say that the claim was filed timely. The Plan denied your 
request. The Plan says the claim was filed beyond the applicable timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the office visit was not filed until August 13, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on August 12, 2021.