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

 
We decided that the Plan does not have to pay for the bronchoscopy (31628) provided on May 19, 2020. 
 
You asked the Plan to pay for the bronchoscopy. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the service 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. 
 
In this case, the CPT Code Manual definition of code 31628 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe. 
 
 
 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 the bronchoscopy. Our reviewer says that CPT code 31628 
does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does 
not support a transbronchial lung biopsy, in this case CPT 31628 is incorrect procedure to report for service 
performed.  There is a more appropriate code to report for service provided. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bronchoscopy have not been met. Therefore, we decided that the Plan does 
not have to pay for the bronchoscopy (31628) provided on May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF 105-gene liquid biopsy testing provided on 
August 1, 2021. 
 
You asked the Plan to pay for the Tempus xF panel. You say that this was medically necessary testing. The 
Plan denied your request. The Plan says this panel needs to be billed with one code. In addition, the POS code 
reported is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus xF panel have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the Tempus xF 105-gene liquid biopsy testing provided on August 1, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on May 6, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on medical necessity. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing services have not been met. Specifically, this claim was billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, 
we decided that the Plan does not have to pay for the genetic testing services provided on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on November 19, 2021. 
 You asked the Plan to pay for the services provided. You say that the most effective therapy for the prevention 
of deep vein thrombosis is intermittent pneumatic compression therapy during surgery. The Plan denied your 
request. The Plan says the service was billed with an inappropriate place of service. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. 
 
We looked at the file and the rules. The facility must furnish all necessary covered services to the beneficiary 
either directly or under arrangements made with outside providers. This service was provided via arrangement 
of the facility. Payment for this service would have been included under the facility claim. Payment to you for 
this service is the responsibility of the facility. Therefore, we decided that the Plan does not have to pay for the 
pneumatic compression device and related supplies provided on November 19, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary to 
monitor the member's condition. The Plan denied your request. The Plan says SNF admission is not medically 
necessary. 
 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found at the time of diagnosis with COVID-19 
and initiation of isolation, the member was medically stable.  She did not require any supplemental oxygen or 
medications specific for infection with COVID-19. The member does not require any skilled nursing or rehab 
services on a daily basis at an inpatient level of care. She is not expected to make measurable gains within a 
reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility. The 
member does not require skilled therapy to establish a safe and effective maintenance program.  The member 
was noted to be at or near her functional and medical baseline. The member does not have any parental 
medication, complex wound care or nutrition given via a feeding tube.  She is medically stable without any 
acute exacerbations of chronic medical problems.  Her physical function is at or near her baseline and can 
receive further services at a lower 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care. 
 
You asked the Plan to pre-approve the continued SNF care. You say that you would like reconsideration 
because the SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare criteria for coverage. 
 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 the continued SNF care. Our reviewer 
says that daily skilled services are not necessary. Our physician reviewer found the member did not have any 
parental medications, complex wound care or nutrition given via a feeding tube.  The member received skilled 
care with minimal improvement; however, her functional improvement had plateaued by May 1, 2022 and she 
did not require any further inpatient skilled rehab services. The members function was at or near her new 
baseline level of function and she could be discharged to a lower level of care for further services.  As of May 
1, 2022, the member required custodial 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued Skilled Nursing Facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia service (01992) provided on October 4, 2021. 
 
You asked the Plan to pay for the anesthesia service. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code 00192 is included in CPT code 
62323. 
 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 01992 is anesthesia for diagnostic or therapeutic nerve 
blocks and injections (when block or injection is performed by a different physician or other qualified health 
care professional); prone position. 
 
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 the anesthesia service. Our reviewer says that CPT code 
01992 does not meet criteria for billing or reimbursement consideration. Our reviewer found anesthesia 
services can be provided with therapeutic injection procedures, when medically reasonable and necessary (per 
CMS) In this case, the medical necessity for anesthesia does not include enough documentation to confirm 
anesthesia service was medically reasonable or necessary, as,Medical necessity form does not list a serious 
medical condition(s) to support medical necessity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia service have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia service (01992) provided on October 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
March 20, 2021, through April 9, 2021. 
 
You asked the Plan to pay for the SNF services. You say that the enrollee required SNF care which should be 
reimbursed. The Plan denied your request. The Plan says this was correctly denied as no daily skilled care was 
required. 
 
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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
patient required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled 
professional nurse were not required to safely and effectively provide medically necessary and reasonable 
treatment. Records did not document the need for intravenous medications, new tube feeding or ostomy care or 
daily complex wound care. Based on the medical records provided, this patient did not require skilled therapy 
services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely 
and effectively provide medically necessary and reasonable treatment from 03/20/2021 through 04/09/2021. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided from March 20, 2021, through April 9, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
October 5, 2021, to October 16, 2021. 
 You asked the Plan to pay for the SNF services. You say that these services should be paid. The Plan denied 
your request. The Plan says the patient had been in the SNF since September 17, 2021, after hospitalization for 
a seizure. The patient's condition no longer qualified for SNF care and the last covered day was October 4, 
2021. 
 
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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found as of October 5, 2021, the patient did not 
require or receive any skilled nursing or rehab services on a daily basis.  He was not expected to make 
measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or activities of daily living.  The patient did not require skilled therapy to establish a 
safe and effective maintenance program.  As a practical matter, the patient did not require any skilled services 
on an inpatient basis, at a SNF level of care as of October 5, 2021. The patient did not have any parental 
medications, complex wound care or nutrition given via a feeding tube, so his care was custodial as of this date. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for skilled nursing facility (SNF) services provided from October 5, 2021, to October 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the pelvis provided on July 11, 2021, billed with code 72192. 
 
You asked the Plan to pay for the CT scan interpretation. You say that this should be paid. The Plan denied 
your request. The Plan says the Column 2 code was not billed with an appropriate modifier.  
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 72192 
is a column II code to column I code 74177. 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 the interpretation of the computed tomography (CT) scan of the 
pelvis provided on July 11, 2021, billed with code 72192.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus Test Strips (A4253). 
 
You asked the Plan to pre-approve Accu-Chek Aviva Plus Test Strips. You say that you would like 
reconsideration because you already use this brand and would prefer to continue with it. The Plan denied your 
request. The Plan says you do not meet the criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose 
testing at least four times per day, use insulin with at least three daily injections or require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of Accu-Chek Aviva Plus Test Strips have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus Test Strips (A4253).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on September 5, 
2021, through September 10, 2021. 
 You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the DRG billed. 
 
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 DRG 092 with primary diagnosis code G92. 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. Our reviewer 
says that the documentation submitted does not support the DRG billed. Our physician reviewer found 
following initial workup, no infection was found, imaging was negative, EEG was unremarkable, and no other 
cause of his symptoms were identified. The most likely cause was medication non-compliance. Toxic 
encephalopathy is not supported sufficiently as the primary diagnosis for this hospital stay, but altered mental 
status would be appropriate.  
 
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 the inpatient hospital services provided on September 5, 2021, through September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on October 26, 2021. 
 
You asked the Plan to pay for the services provided. You say that specimens are collected to perform 
diagnostic tests independent of an institution or physician's office. The Plan denied your request. The Plan says 
the place of service is not applicable. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
The file shows that hereditary cardiovascular genetic testing was provided. We looked at the file and Medicare 
rules. The records show that the specimen was obtained at the enrollees home. The claim was billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab testing services provided on October 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap (15734), 
postoperative follow-up visit (99024) and debridement (11042) provided on November 1, 2021. 
 
You asked the Plan to pay for the muscle, myocutaneous, or fasciocutaneous flap, postoperative follow-up visit 
and debridement. You say that you would like reconsideration based on the records submitted. The Plan denied 
your request. The Plan says the documentation submitted does not support the services 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. 
 
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 the muscle, myocutaneous, or fasciocutaneous flap, 
postoperative follow-up visit and debridement. Our reviewer says that CPT codes 15734 and 1573459 do not 
meet criteria for billing or reimbursement consideration. The operative report does not describe a prepared flap from a donor area rotated to the site needing repaired. Our reviewer found CPT code 11042 does not meet 
criteria for billing or reimbursement consideration. Operative report describes debridement was performed 
when opening a prior laparotomy incision. (of note, no measurements of debridement were documented in the 
operative report). This procedure would not be reported separately from the primary procedure repair recurrent 
incisional or ventral hernia.  Reopening of the prior incision would be performed prior to repairing the hernia.  
Therefore, this procedure would be inclusive to primary procedure. Additionally, CPT code 99042 has a status 
indicator of B. This means that the payment for CPT code 99042 is always bundled into the payment for 
another service or procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the muscle, myocutaneous, or fasciocutaneous flap, postoperative follow-up 
visit and debridement have not been met. Therefore, we decided that the Plan does not have to pay for muscle, 
myocutaneous, or fasciocutaneous flap (15734), postoperative follow-up visit (99024) and debridement 
(11042) provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing, column 
chromatography, and mass spectrometry provided on April 27, 2021. 
 
You asked the Plan to pay for the drug testing and other related tests. You say that this was medically necessary 
testing. The Plan denied your request. The Plan says this claim was not billed with the appropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing and other related tests have not been met. Specifically, this claim was billed with 
the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing, 
column chromatography, and mass spectrometry provided on April 27, 2021.