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

 
We decided that the Plan does not have to pay for lab services (83789) provided on May 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for lab services (83789) provided on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 27, 2022, billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81355, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. 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. 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 
January 27, 2022, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81355, 0031U, 0032U, and 
0033U.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing (0037U) billed for date of service August 19, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says that the date of service for a clinical 
laboratory test or the technical component of physician pathology service must be the date the specimen was 
collected. The record shows that the specimen was collected on July 4, 2021, rather than the billed date of 
service of August 19, 2021. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory services should be reported with 
the date of specimen collection as the date of service; however, there are three exceptions to this rule. The rules 
also say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE 
information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not acknowledged nor addressed the exceptions to the 
applied rule. The record indicates that the specimen in this case is a piece of live tissue/tumor which would 
have been collected as part of a biopsy/procedure in a hospital setting. It is very likely that an exception has 
been met in this case, which would mean that the date the testing was performed, August 19, 2021, would be 
the correct date of service to report. Therefore, we decided that the Plan has to pay for laboratory testing 
(0037U) billed for date of service August 19, 2021.  
 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 lab services (80307, G0480) provided on January 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were ordered by the enrollee's 
physician and are supported as billed. The Plan denied your request. The Plan says you billed with an incorrect 
place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services (80307, G0480) provided on January 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple repair of superficial wounds (CPT code 12002) 
provided on February 2, 2022. 
 
You asked the Plan to pay for procedure code 12002. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 12002 is bundled into payment for code 26770. 
 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 12002 
is a column II code to column I code 26770. 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 simple repair of superficial wounds (CPT code 12002) 
provided on February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 27, 2022 billed with 
codes 81206, 81210, 81235, and 81275. 
 
You asked the Plan to pay for the genetic testing billed. 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 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 
January 27, 2022 billed with codes 81206, 81210, 81235, and 81275.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PCD (CPT code E0675) provided from January 12, 2022, 
through February 2, 2022. 
 
You asked the Plan to pay for the DME. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 DME have not been met. A PCD coded as E0675 is used only 
for peripheral artery disease". The documentation/order submitted does not support the diagnosis required to 
support the pneumatic compression device billed. The face-to-face encounter must support payment for the 
item(s) ordered/prescribed and be documented in the pertinent portion of the medical record (for example, 
history, physical examination, diagnostic tests, summary of findings, progress notes, treatment plans or other 
sources of information that may be appropriate). The supporting documentation must include subjective and objective beneficiary specific information used for diagnosing, treating, or managing a clinical condition for 
which the DMEPOS is ordered. Progress notes submitted do not include mention of ordering or utilizing DME 
for treatment. In addition, documentation submitted is missing the proof of delivery to support code E0675 for 
date of service January 12, 2022. Therefore, we decided that the Plan does not have to pay for the PCD (CPT 
code E0675) provided from January 12, 2022, through February 2, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 provided on May 17, 2022. 
 
You asked the Plan to pay for procedure code 99284. You say that you would like the Plan to reconsider their 
denial of payment. 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 procedure code 99284 is included in the global surgery 
payment for procedure code 28003 provided on the same date. Separate payment cannot be made for procedure 
code 99284. Based on this information, we decided that Medicare rules for coverage of procedure code 99284 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99284 
provided on May 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 1, 
2022 to March 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 1, 2022 to March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 13, 2021 billed 
with codes 81225 and 81226. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
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 
December 13, 2021 billed with codes 81225 and 81226.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service April 2, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99140 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 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service April 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction of peripheral nerve or branch (CPT code 
64640). 
 
You asked the Plan to pre-approve the service. You say that this is necessary for the doctor's plan of care. The 
Plan denied your request. The Plan says Medicare does not cover procedures that are experimental or 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found genicular nerve blocks are considered experimental/ investigational for the treatment of 
osteoarthritis; therefore, the request is deemed 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction of peripheral nerve or branch (CPT code 64640).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation that the oxygen saturation (SpO2) can be maintained at greater 
than 91 percent during activity while using an oxygen conserving device on 1 to 4 L/min of oxygen. Also, the 
refillable D tanks are similar in weight to a portable oxygen concentrator. 
 
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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested item is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested item is 
experimental/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 MyoPro orthosis. Our reviewer says 
that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that current clinical guidelines designate robotic therapy to be of "uncertain utility compared 
with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home 
environment. In addition, the provided records report left upper extremity spasticity which may be a 
contraindication to use of the device. 
 
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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial preventive physical examination provided on 
January 14, 2022. 
 
You asked the Plan to pay for the initial preventive physical examination. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says this service is only covered within the first 12 
months of Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the initial preventive physical examination is 
limited to new enrollees during the first 12 months of Medicare enrollment.  
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee's first Medicare coverage 
period was effective January 1, 2020. The documentation shows that more than 12 months had passed since the 
enrollee enrolled in Medicare. This means this service is not payable. Based on this information, we decided 
that Medicare rules for coverage of the initial preventive physical examination have not been met. Therefore, we decided that the Plan does not have to pay for the initial preventive physical examination 
provided on January 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs represented by code A9270 
provided on December 14, 2021. 
 
You asked the Plan to pay for the self-administered drugs (A9270). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the self-administered drugs 
provided are not covered under the enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
represented by code A9270 provided on December 14, 2021.  
 
Benefits for the self-administered drugs (A9270) may be available under Medicare Part D. Contact the Plan 
that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 5, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on June 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says this procedure is considered 
experimental/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 Intracept procedure. 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 to show safety and 
efficacy before coverage can be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code 
64483) provided on April 7, 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. Per 2022 National Physician Fee 
Schedule Relative Value File January Release the Bilateral indicator is 1 for the procedure code 64483. Code 
64483 was not billed in accordance with Medicare National Correct Coding Initiative Policy - Medically 
Unlikely Edits (MUE). The procedure code 64483 has an MUE value of 1, you billed 1 unit of 64483-RT and 1 
unit of 64483-LT. Therefore, the claim not coded correctly for a bilateral procedure. Therefore, we decided that 
the Plan does not have to pay for the injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, 
with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (CPT code 64483) provided on April 
7, 2022.