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

 
We decided that the Plan does not have to pay for an exploration of spinal fusion (22830) and a posterior 
segmental instrumentation procedure (22842) billed for date of service January 3, 2022. 
 
You asked the Plan to pay for an exploration of spinal fusion and a posterior segmental instrumentation. You 
say that you have provided documentation to support the services billed. The Plan denied your request. The Plan says rules for payment have not been met because the CPT codes at issue are included in other billed 
codes. 
 
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 codes 22830 and 22842 are column II codes to column I codes 22612 and 
22849, respectively; however, 22830 and 22842 were billed with a modifier to bypass the edits. 
 
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 an exploration of spinal fusion and a posterior segmental 
instrumentation. Our reviewer says that the CPT codes at issue do not meet criteria for payment. Our reviewer 
found that there is an edit that exists between procedure codes 22612 and 22830. The available medical 
documentation does not support the use of modifier 59 as distinct and independent procedures being done. 
Spinal exploration was already being done on this spinal level with the procedure described by CPT code 
22612. Additionally, there is an edit that exists between procedure codes 22842 and 22849. Medical 
documentation has already documented the process of insertion of the instrumentation and the use of modifier 
59 would not be appropriate in this as the area of instrumentation is concurrent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an exploration of spinal fusion and a posterior segmental instrumentation have 
not been met. Therefore, we decided that the Plan does not have to pay for an exploration of spinal fusion 
(22830) and a posterior segmental instrumentation procedure (22842) billed for date of service January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on 
December 17, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was seen by different specialists. 
The Plan denied your request. The Plan says only one evaluation service may be reported. 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 looked at the file and the rules. We find that the service at issue was provided on the same day as a 
previous evaluation service. The providers were from the same group practice and of the same specialty. 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 evaluation and management services provided 
on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for optometry visit provided on April 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for optometry visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 optometry visit provided on April 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne testing (0037U) provided on February 10, 
2022. 
 
You asked the Plan to pay for FoundationOne testing.. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, 
providers should enter the appropriate DEX Z-Code identifier adjacent to the Current Procedural Terminology 
(CPT) code in the comment/narrative field on the claim. 
 
We looked at the file and Medicare rules. A DEX Z-Code identifier was not reported on the claim for this 
Molecular Diagnostic Test service. Based on this information, we decided that Medicare rules for coverage of 
FoundationOne testing. have not been met. Therefore, we decided that the Plan does not have to pay for 
FoundationOne testing (0037U) provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 16, 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 covered. 
 The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 laboratory services 
rendered on December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 22, 2021 billed 
with codes 81206, 81235, 81210, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 22, 2021 billed with codes 81206, 81235, 81210, and 81272.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenetic panel testing provided on October 1, 
2021.  
 
You asked the Plan to pay for the testing services. You say that the billed charges are appropriate for the level 
of acuity. The Plan denied your request. The Plan says providers must not unbundle the 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. 
 
We find that the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the pharmacogenetic panel testing provided on October 1, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (81455) billed for date of service April 15, 2022. 
 
You asked the Plan to pay for genetic testing. You say that these services were necessary and are supported in 
the medical records. The Plan denied your request. The Plan says that this claim was billed with an incorrect 
date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that unless a specific exception is met, the date of 
service billed for a laboratory claim should be the date of service of the specimen collection.  
 
We looked at the file and Medicare rules. The record indicates that the specimen at issue was collected during 
an outpatient hospital stay during a surgical procedure (biopsy). It was medically appropriate to collect this 
sample during this procedure and the results of this test did not guide treatment during this hospital care. Based 
on this information, an exception to the general rule has been met, and the appropriate date of service for this 
claim is the date the test was performed. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have been met. Therefore, we decided that the Plan has to pay for genetic testing 
(81455) billed for date of service April 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 laboratory services rendered on March 8, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. There is no evidence in the file that the ordering provider was 
treating the patient. Without a record showing that this provider is treating the enrollee, the criteria for coverage 
of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on March 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic abdominal ultrasound provided 
on April 12, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic abdominal ultrasound. You say that you are 
contesting the copayment that was applied to this service. The Plan denied your request. The Plan says the 
copayment that was applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $115 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay the allowed amount of $103.25, which is less than the $115 copayment for a 
diagnostic abdominal ultrasound. A diagnostic abdominal ultrasound falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic abdominal 
ultrasound provided on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing procedures coded 88341, 88342, 88360 
and 88381 billed for date of service December 15, 2021. 
 
You asked the Plan to pay for laboratory testing. You say that the services at issue were billed correctly. The 
Plan denied your request. The Plan says rules for payment have not been met because the services at issue 
require modifier -26. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made under the physician fee 
schedule for the professional component of physician laboratory or physician pathology services furnished to 
hospital inpatients or outpatients. 
 
We looked at the file and Medicare rules. In this case, the professional and technical components were provided in different settings. The claims at issue were not billed with modifier -26 to indicate the professional 
component. Based on this information, we decided that Medicare rules for coverage of laboratory testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing procedures 
coded 88341, 88342, 88360 and 88381 billed for date of service December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88341, 88342) billed for date of service 
December 27, 2021. 
 
You asked the Plan to pay for pathology services. You say that these services were billed appropriately. The 
Plan denied your request. The Plan says these services were not billed in accordance with Medicare rules and 
are missing a necessary modifier for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT codes 88341 and 88342 are physician pathology services which have both professional 
components (PC) and technical components. These services were not billed with modifier 26 to indicate that 
only the professional component payment is requested. This means that payment is requested for both the PC 
and TC of these services. However, these services were provided to an enrollee who was in an outpatient 
hospital setting at the time the sample was collected, which means that the TC component is bundled into the 
facility payment. The TC portion of these services are not separately payable, and therefore these services are 
not supported as billed. Based on this information, we decided that Medicare rules for coverage of pathology 
services have not been met. Therefore, we decided that the Plan does not have to pay for pathology services 
(88341, 88342) billed for date of service December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 7, 2022 billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 0031U, 0032U, 0033U, 81407 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 7, 2022 billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81355, 0031U, 0032U, 
0033U, 81407 and 81238.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Myo Pro 2 Motion G device (L8702). 
 
You asked the Plan to pre-approve a Myo Pro 2 Motion G device. You say that the MyoPro would immediately 
restore your arms function and range of motion by allowing you to control motors at the elbow and hand 
portions of the brace. The Plan denied your request. The Plan says the requested device is not indicated for 
patients with upper-extremity weakness or paresis and is considered experimental and 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 Myo Pro 2 Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 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 Myo Pro 2 Motion G device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Myo Pro 2 Motion G device (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care 
provided from March 31, 2021, to April 5, 2021. 
 You asked the Plan to pay an additional amount for the inpatient care. You say that the documentation supports 
the billing of the principal diagnosis code. The Plan denied your request. The Plan says the documentation does 
not support the billing of the principal diagnosis code, J15.6. 
 
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 principal diagnosis code J15.6, defined as 
pneumonia due to other Gram-negative bacteria. 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 an 
additional amount for the inpatient care. Our reviewer says that the billing of the primary diagnosis code is not 
supported. Our physician reviewer found the provided documentation does support the presence of pneumonia. 
However, there was no evidence of microbiological confirmation of a gram-negative organism as the diagnosis 
code describes. Therefore, the reviewer found that the billing of the principal diagnosis code, J15.6, is not 
supported.  
 
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 
an additional amount for the acute inpatient hospital care provided from March 31, 2021, to April 5, 2021.
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 25, 2022, to March 21, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
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, a valid NOA 
document must be submitted for the services billed. Review of the file shows that a valid NOA was not submitted. Therefore, we decided that the Plan does not have to pay for the home health services provided to 
the enrollee from February 25, 2022, to March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on February 9, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered 
for CxBladder testing.  
 
We looked at the file and Medicare rules. Per L35396, the requested CxBladder testing is not covered when 
billed with code 0012M. 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 CxBladder testing provided 
on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (62323). 
 
You asked the Plan to pre-approve the repeat injection. You say that the enrollee's last injection was June 27, 
2022. You say that the enrollee is reporting a 70% reduction in pain a month later. You also say that a series of 
injections has helped to control the enrollee's pain for an extended period of time. The Plan denied your 
request. The Plan says the repeat injection is not medically reasonable or necessary. 
 
{***Add rules/contract recap and to complete decision section. For example: 
 
"The Plan follows Medicare rules. Medicare rules say that ESIs are limited to a maximum of four sessions per 
spinal region in a rolling 12-month period. 
 
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 repeat injection. Our reviewer says 
that the requested injection is not medically necessary. Our physician reviewer found the provided 
documentation indicates that the enrollee has received previous epidural steroid injections (ESIs) on November 3, 2021, May 3, 2022, June 15, 2022, and June 27, 2022. The guidelines allow for 4 ESIs in a 12-month period. 
The requested injection would be the fifth. Therefore, the reviewer found that the requested injection is not 
medically reasonable or 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 repeat injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat epidural steroid injection (62323).