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

 
We decided that the Plan does not have to pre-approve coagulation factor V (F5 gene) genetic testing services. 
 
You asked the Plan to pre-approve F5 gene genetic testing services. You say that this testing is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says this testing is not covered 
by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that F5 gene (coagulation factor V) genetic tests are 
not considered to be clinically efficacious. Therefore, F5 gene genetic testing is not medically necessary. Based 
on this information, we decided that Medicare rules for coverage of F5 gene genetic testing services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve coagulation factor V (F5 gene) 
genetic testing services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 18, 2020, to 
November 20, 2020. 
 
You asked the Plan to pay for the inpatient services. You say that the hospital stay met inpatient criteria. The 
Plan denied your request. The Plan says that the enrollee did not require a prolonged or more intensive 
treatment. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 services. Our physician 
reviewer found that the enrollee presented to the emergency room with shortness of breath. The physical exam 
in the emergency department showed no acute distress, no respiratory distress, normal breath sounds, speaks in 
full sentences, regular heart rate and rhythm, equal pulses, normal range of motion, and normal motor and 
sensation. Upon reassessment, new anemia without a clear source of bleeding likely contributed to her 
continued shortness of breath. She was admitted for a transfusion and continued management and monitoring. 
The review has determined that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
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 inpatient services have been met. Therefore, we decided that the Plan has to 
pay for the acute inpatient hospital care provided from November 18, 2020, to November 20, 2020.  
 
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 genetic testing provided on July 1, 2022, billed with 
codes 87481, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, 87798, 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are an independent diagnostic 
laboratory that tests pathology, medication management and toxicology samples sent from clinics and 
providers for patients they have determined require such testing. 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 
July 1, 2022, billed with codes 87481, 87491, 87496, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 
87653, 87661, 87798, 87500.
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 25, 
2022. 
 
You asked the Plan to pay for procedure code 99100. 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 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service August 2, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 77001. 
 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 71045 
is a column II code to column I code 77001. 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 71045 billed for date of service August 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need a doctor oversight because of your 
breathing and high blood pressure. You say that you need intensive physical therapy every day to be able to 
gain your independence you had before your fall. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and your needs can be met at an alternate level of care. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on October 5, 
2021. 
 
You asked the Plan to pay for the transportation services. The Plan denied your request. The Plan says the 
primary group health plan has not been billed. 
 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the ambulance transportation services provided on October 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 18, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date 
of service. 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 code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 August 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 30, 2021, to 
May 5, 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 these 
services were reported correctly and are supported as billed. The Plan denied your request. The Plan says DRG 
submitted on this claim 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 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 gram-negative sepsis (A41.50). 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 this diagnosis is not supported in the medical record. Our physician reviewer found that 
the enrollee with a past medical history of hypertension and recurrent urinary tract infections presented with 
altered mental status, vomiting and drooling. Vital signs included temperatures of 102.2-100.4 degrees 
Fahrenheit, a heart rate of 97, respiratory rate of 16, blood pressures of 160/92-181/104-195/95, and oxygen 
saturation of 96%. The enrollee was lethargic with a Glasgow coma scale of 14. The lab results included white 
blood cell counts of 12.9-18.2-11.0, lactic acid 0.9, platelet count 265, and bilirubin 0.8. Urinalysis showed 
large leukocyte esterase. Urine culture showed 100,000 Pseudomonas. Blood cultures showed no growth at five 
days. The procalcitonin level was not obtained and the liver enzymes were normal. A computerized 
tomography (CT) scan of the brain showed no acute abnormality. Chest x-ray showed mild bilateral lung 
infiltrates. An ultrasound of the kidneys showed bilateral hydronephrosis. The enrollee was admitted for 
pyonephrosis and treated with intravenous antibiotics and fluids, and a Foley catheter was place. In this case, 
there was no clinical or laboratory evidence of gram-negative sepsis. The review has determined that gram-
negative sepsis (A41.50) was not supported in the medical record. 
 
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 April 30, 2021, to May 5, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80307, G0480) provided on July 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says out-of-network care is covered only in certain limited 
circumstances which have not been met in this case. Neither the laboratory provider nor the referring provider 
are contracted with the Plan. These services were not urgent, emergent or pre-approved. 
 
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 and the referring provider in this case are not network providers 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 laboratory services (80307, 
G0480) provided on July 20, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on May 11, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was necessary for the management of 
the enrollee's advanced cancer. The Plan denied your request. The Plan says the claim did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. A review of the claim does not show that the required unique 
identifier was reported. 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 the lab testing services 
provided on May 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve ablation/destruction (Iovera) (64640). 
 
You asked the Plan to pre-approve Iovera. You say that you believe this treatment is justified and reasonable. 
The Plan denied your request. The Plan says the guidance appears to confer no or unclear support for the Iovera 
system for treatment of knee pain due to osteoarthritis. 
 
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 Iovera. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is considered experimental and investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Iovera have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a peripheral nerve ablation/destruction (Iovera) (64640).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the in-home physical therapy (PT) visit provided on 
July 26, 2022. 
 
You asked the Plan to pre-approve the in-home PT visit. You say that you greatly improved with physical 
therapy. The Plan denied your request. The Plan says Medicare criteria for home physical therapy services are 
not met and medical necessity is not established. 
 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 in-home PT visit. Our reviewer says 
that the in-home physical therapy visit was not reasonable and necessary. Our physician reviewer found there is 
no documentation that skilled PT services were required to effectively provide treatment, care, and/or services 
in order to improve your level of function, or to establish/perform a maintenance program to maintain your 
level of function and/or prevent deterioration on July 6, 2022. Our reviewer found that the records indicate you 
had been instructed on a home exercise program. Provided records do not document any acute or unstable 
medical conditions or injuries which would necessitate any further skilled PT visits beyond what had already 
been approved. Our physician reviewer also found that no medical notes from your treating physician are 
provided documenting an order or need for additional skilled PT services.  
 
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 in-home PT visit have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the in-home physical therapy (PT) visit provided on July 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that that the enrollee will benefit from acute inpatient 
rehab that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and the enrollee's needs can be provided safely in other settings. 
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that the patient was seen by multiple providers 
on this date of service, so this code is not bundled. The Plan denied your request. The Plan says payment for 
code 99291 is bundled into payment for code 36620. You did not bill with a modifier that would allow for 
payment.  
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 99291 
is a column II code to column I code 36620. 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 99291 billed for date of service May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 23, 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 a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The documentation shows a definitive urinary drug testing panel for multiple drug classes was performed but 
does not show screening test results which are positive or inconsistent with prescription medications, dosing 
schedules, or history and expected results. This means that the drug test at issue in this appeal was requested 
solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we 
decided that the Plan does not have to pay for the drug testing coded G0483 provided on June 23, 2022.