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

 
We decided that the Plan does not have to pre-approve the Sprint peripheral nerve stimulator (PNS) system. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this service is helpful for the treatment of the 
health problem. 
 
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 this would be considered an experimental/investigational procedure since there is no literature to 
support the use of Sprint for tarsal tunnel syndrome. Therefore, the request is deemed not medically reasonable 
and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Sprint peripheral nerve stimulator (PNS) system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on January 6, 2022. 
 
You asked the Plan to pay for the drug testing. 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 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 documentation does not 
support drug testing of 22 or more drugs. 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 January 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for revision spinal surgery. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the enrollee is in pain. The Plan denied 
your request. The Plan says studies have not proven that this is helpful for the enrollee's condition. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental for use in spine fusion surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate for revision spinal surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 8, 2021, to 
November 17, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code G93.41, described as 
septic encephalopathy. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that documentation does not support the billed code. 
Our physician reviewer found the enrollee was an 86-year-old male who presented to the facility on November 
8, 2021 with a change in mental status and worsening weakness and fatigue. The past medical history included 
hypertension, atrial fibrillation, hyperlipidemia, coronary artery disease, and dementia. The enrollee was 
admitted and diagnosed with an acute right cerebellar vascular accident (CVA). In this case, review of the 
medical record reveals that the patient's altered mental status can be primarily attributed to the CVA. The 
review has determined that the documentation did not support code G93.41.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 8, 2021, to November 17, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
12, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim denied as a duplicate in error. 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 September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on September 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 Testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested. 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 lab services 
(G0483) provided on September 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on September 5, 2022, billed 
with code 51798-XE. 
 
You asked the Plan to pay for radiology services provided. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says documentation does 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 51798-XE is measurement of post-voiding residual urine 
and/or bladder capacity by ultrasound, non-imaging. 
 
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 radiology services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found Per Centers for Medicare and Medicaid 
services code 51798, should not be performed more than once per day. Services that exceed this parameter will 
be considered not medically necessary. Documentation does not include documentation to support additional 
bladder scan, and therefore cannot be verified.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiology services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for radiological services provided on September 5, 2022, billed with code 51798-XE.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on September 15, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were reported correctly. The Plan 
denied your request. The Plan says that the code used to report these services is not supported in the medical 
record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the record supports that 19 drug 
classes were tested in this case, including alcohol biomarkers, amphetamines, benzodiazepines, buprenorphine, 
cannabinoids (natural), cocaine, fentanyls, gabapentin (non-blood), heroin metabolite, methadone, 
methylenedioxyamphetamines, opiates, opioids and opiate analogs, oxycodone, phencyclidine, pregabalin, 
skeletal muscle relaxants, tapentadol and tramadol. Based on this information, we decided that Medicare rules 
for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug 
testing (G0482) provided on September 15, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel (87150, 
87798, 87481, and 87801) provided on February 3, 2022, 
 
You asked the Plan to pay for the urine PCR panel. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this panel is considered infectious 
disease pathogen identification, but this panel was billed with multiple components rather than a single panel 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infectious disease pathogen identification testing have not been met. Specifically, the records show that a single panel was ordered and performed, but this service was billed by reporting individual components. 
Therefore, we decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel 
(87150, 87798, 87481, and 87801) provided on February 3, 2022,
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extended respiratory pathogen panel billed for date of 
service August 18, 2022, with codes U0005, 87496, 87498, 87541, 87798, 87801, 87503, and 87632. 
 
You asked the Plan to pay for the extended respiratory pathogen panel. You say that this testing was necessary 
and is supported in the medical record. The Plan denied your request. The Plan says this panel was unbundled 
and billed with multiple codes, which does not follow Medicare billing guidelines. In addition, respiratory 
panels of more than 5 pathogens are considered not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that a respiratory pathogen panel test must not be unbundled and billed as individual components regardless of the fact that the panel reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the extended respiratory pathogen panel have not been met. Specifically, the records show that a 
single panel was ordered and performed, but this service was billed by reporting individual components. 
Therefore, we decided that the Plan does not have to pay for the extended respiratory pathogen panel billed for 
date of service August 18, 2022, with codes U0005, 87496, 87498, 87541, 87798, 87801, 87503, and 87632.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on September 27, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that psychotherapy services are covered when the 
provider is one of the following: 
Physicians (Medical Doctors [MDs] and Doctors of Osteopathy [DOs]), particularly  
Psychiatrists 
Clinical Psychologists (CPs) 
Clinical Social Workers (CSWs) 
Clinical Nurse Specialists (CNSs) 
Nurse Practitioners (NPs) 
Physician Assistants (PAs) 
Certified Nurse-Midwives (CNMs) 
Independently Practicing Psychologists (IPPs) 
Certified Registered Nurse Anesthetists (CRNAs) 
 
We looked at the file and Medicare rules. Review of the file does not support that the provider of the 
psychotherapy service was one listed above as covered. Based on this information, we decided that Medicare 
rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does 
not have to pay for the psychotherapy services provided on September 27, 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 you are just getting well and your strength back you 
live alone and no one to take care of you. The Plan denied your request. The Plan says your needs can be met at 
a long-term care facility or private setting with caregivers and Part B therapy 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 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 pay for the surgical services billed with code 27703 for July 13, 
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 are not covered at the outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for an inpatient-only service 
furnished to a person who is registered in the hospital as an outpatient. 
 
We looked at the file and Medicare rules. The file shows that procedure code 27703 is an inpatient-only 
procedure for year 2022 and was billed as an outpatient claim. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the surgical services billed with code 27703 for July 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87640, 87481, 87563, 87491) billed for 
date of service September 7, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these codes and the reported diagnosis are 
covered by Medicare guidelines. The Plan denied your request. The Plan says there is insufficient 
documentation to support these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, no medical records were provided for these services. Without this documentation, we cannot 
verify the medical necessity of these tests, if they were ordered by a physician who is treating the enrollee, or 
whether they were reported accurately. Therefore, we decided that the Plan does not have to pay for laboratory 
services (87640, 87481, 87563, 87491) billed for date of service September 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 31, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 31, 
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 
29, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly 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 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that the item is necessary. The Plan denied 
your request. The Plan says the requested item is not covered since you currently reside in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a manual wheelchair is being requested for use in a SNF or hospital. Therefore, we decided 
that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 1, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim denied as a duplicate in error. 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 December 1, 2022.