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

 
We decided that the Plan does not have to pay for procedure codes 83986 and 82570 billed for date of service 
March 29, 2022.  
You asked the Plan to pay for procedure codes 83986 and 82570. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 83986 and 82570 is bundled into 
payment for code 80307. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that codes 83986 and 82570 are column II codes to column I code 80307. 
While codes 83986 and 82570 were billed with modifier -59, the medical records provided do not show that the 
services billed with the -59 modifier are a distinct procedural service. Codes 83986 and 82570 cannot be 
separately reimbursed when billed for specimen validity testing on urine specimens utilized for drug testing. 
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 83986 and 82570 billed for date of service March 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on July 12, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that pre- and post-operative care is included in the global 
surgical package. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99213 was billed within the 10 
day global surgical period for minor procedure 11042 billed on July 12, 2022. Code 99213 was related to the 
minor procedure and payment is therefore included in the global surgical package. Therefore, we decided that 
the Plan does not have to pay for the office visit rendered on July 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound rendered on April 4, 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. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for the ultrasound rendered on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00400) provided on April 4, 2022. 
 
You asked the Plan to pay for procedure code 00400. 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 providers must report services correctly. 
 
We find that code 00400 is not supported in the medical record. Specifically, in order for anesthesia services to 
be paid, the code must be billed with the appropriate modifier. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services (00400) provided on April 4, 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 enrollee cannot be released without inpatient 
rehabilitation. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee may need physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transcatheter aortic valve replacement (TAVR/TAVI) with 
prosthetic valve; percutaneous femoral artery approach (CPT code 33361) provided on June 9, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. A review of our claims system 
shows Clinical Trial number was not billed on claim. The denial for Clinical Trial number per the 2150 Review 
for Coverage with Evidence Development (CED) Review is required criteria defined by the appropriate 
National Coverage Determination or a Reimbursement policy. Therefore, we find the Medicare rules for 
payment as not been met. Therefore, we decided that the Plan does not have to pay for transcatheter aortic 
valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach (CPT code 
33361) provided on June 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) billed for date 
of service December 11, 2021. 
 
You asked the Plan to pay for hospital discharge management. You say that this service is supported as billed. 
The Plan denied your request. The Plan says this service 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 99239 is hospital discharge day management; more than 30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the medical record. Without this information, a time-based code such as 99239 cannot be 
verified. Based on this information, we decided that Medicare rules for coverage of hospital discharge 
management have not been met. Therefore, we decided that the Plan does not have to pay for hospital 
discharge day management (99239) billed for date of service December 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees medical 
condition. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in 
patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, 
from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of 
moderate spinal stenosis (including the planned level of implantation of L4-5.). FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the 
medical records. There is no discussion of spinal instability on flexion/extension films. There is no 
documentation of the enrollees height, weight or body mass index. There is imaging evidence of left L2 apex 
levoscoliosis of the lumbar spine, with no documentation of the Cobb angle. There is no discussion indicating 
that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested Vertiflex Superion interspinous device at the L4-5 level, in this case, 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs (J3490) provided on June 10, 2022. 
 
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says payment is included in 
the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 We looked at the file and Medicare rules. Payment for the requested services (J3490) is included in the global 
surgery payment for the procedure (27096) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the drugs have not been met. Therefore, we decided that the Plan 
does not have to pay for the drugs (J3490) provided on June 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute-care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical 
necessity for you. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you do not require services at the LTACH that are not available at the acute-care 
hospital where you are currently receiving care. All medically necessary care is being provided in the current 
acute-care setting. There are no services available at the LTACH that you require that are not available at the 
health-care setting being offered by the Plan. The Plan has approved ongoing care in the current acute-care 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute-care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 84480, 84439, 84443 
and 84481) provided on December 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. National Correct Coding 
Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 84481 and 84480. This PTP edit has a 
modifier indicator of 0, which indicates there are no modifiers that are allowed with this PTP code pair. 
 
Furthermore, 88439, 84443 and 84481 are not supported. The place of service on the CMS-1500 form line 24B 
must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates 
the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation 
and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory 
results submitted indicate the specimen was collected on December 21, 2021, and received by the lab on 
December 22, 2021; therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (CPT code(s): 84480, 84439, 84443 and 84481) provided on December 
22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept back procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure is experimental. More research is 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 the intracept 
back procedure (CPT code 64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 0031U, 0032U, 81225, 
81226, 81227, 81230, 81231, 81240, 81241, 81291, 81355, 81401 and 81479) provided on March 17, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Review of the file shows 
the enrollee had molecular pharmacogenetic testing on March 17, 2022. The denial remains upheld as non-
covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so one CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 0031U, 0032U, 81225, 81226, 81227, 81230, 81231, 81240, 
81241, 81291, 81355, 81401 and 81479) provided on March 17, 2022.
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 April 
22, 2022, to May 6, 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 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, per the 
above guidelines beneficiaries receiving HH services in 2021 whose services will continue in 2022, the HHA 
shall submit an NOA with a one-time, artificial 'admission' date corresponding to the from" date of the first 
period of continuing care in 2022. Per the members claims history, the NOA claim with the onetime, artificial 
'admission' date was billed as January 22, 2022. Subsequent reporting of the admission/start of care date for 30-
day period of care claim April 22, 2022, through May 06, 2022, was reported as December 23, 2021. 
Therefore, as required data element admission/start of care date, on the 30-day period of care claim does not 
match the one-time, artificial 'admission' date on the NOA claim we find the Medicare rule for reimbursement 
of this April 22, 2022, through May 06, 2022, claim has not been met. Therefore, we decided that the Plan does 
not have to pay for the home health services provided to the enrollee from April 22, 2022, to May 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endoscopic retrograde cholangiopancreatography 
(ERCP); with biopsy, single or multiple (CPT code 43261-59) provided on January 26, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT codes have been written as precisely as possible to not only describe a specific procedure but to also avoid 
describing similar procedures which are already defined by other CPT codes. When a CPT code is reported, the 
physician or non-physician provider must have performed all of the services noted in the descriptor unless the 
descriptor states otherwise. (Occasionally, a CPT code descriptor will identify certain services that may or may 
not be included.) A CPT code should not be reported out of the context for which it was intended. When the 
procedure described by CPT code 43261 is reported with the procedure described by CPT code 43276, 
reporting the former code represents a misuse of this code, and separate payment is not allowed. Therefore, we 
decided that the Plan does not have to pay for the endoscopic retrograde cholangiopancreatography (ERCP); 
with biopsy, single or multiple (CPT code 43261-59) provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the catheter placement rendered on May 20, 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 modifier -50 indicaates a bilateral procedure. 
 
We looked at the file and Medicare rules. The file shows that add-on code 36227 was incorrectly billed with 
the -50 modifier. The add-on code does not require a laterality modifier when billed with a bilateral primary 
procedure. Therefore, we decided that the Plan does not have to pay for the catheter placement rendered on 
May 20, 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 June 7, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee 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 June 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis, 51 or greater genes 
(81455) provided March 30, 2022. 
 
You asked the Plan to pay for the NGS LB Liquid Biopsy panel. You say that please review the appeal for 
proving medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for the repeat NGS LB Liquid biopsy panel. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules says that Next Generation Sequencing (NGS) as a 
diagnostic laboratory test is reasonable and necessary and covered when a patient has not been previously 
tested with the same test using NGS for the same cancer genetic content. The records show that the enrollee 
was previously tested on April 14, 2020. Based on this information, we decided that Medicare rules for 
coverage of the NGS LB Liquid Biopsy panel have not been met. Therefore, we decided that the Plan does not 
have to pay for targeted genomic sequence analysis, 51 or greater genes (81455) provided March 30, 2022.