Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the subsequent hospital care services billed with codes 99233 and 
99232, provided from May 16, 2022, to May 19, 2022. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says that payment is included in the fee for the procedure. 
 
The Plan must follow Medicare rules. The rules 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. Review of the file shows that the Plan states that the payment for these services 
are included in the fee for the procedure. The documentation did not include information regarding what 
procedure these services are considered included in. The documentation did not include a claim for the 
procedure that these services were included in. No other denial rationale was provided. Therefore, the Plan did 
not substantiate their denial. Therefore, we decided that the Plan has to pay for the subsequent hospital care 
services billed with codes 99233 and 99232, provided from May 16, 2022, to May 19, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (CPT code(s): 63047-AS, 63048-AS, 
61783-AS and 63047) provided on July 25, 2022. 
 
You asked the Plan to pay for the surgical 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Review of the records indicate a NCCI PTP edit 
exists between 63047 and 22214, between 61783 and 63047, and between 63047 and 22214. This PTP edit has 
a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate 
NCCI modifier was not billed with this PTP code edit. As per Type I - A Type I add-on code 63048 appropriate 
Primary Codes are 63045, 63046 and 63047 and Add-on procedure code 63048 has been submitted without an 
appropriate primary procedure. The CR lists the Type I add-on codes with their acceptable primary procedure 
codes. A Type I add-on code, with one exception, is eligible for payment if one of the listed primary procedure 
codes is also eligible for payment to the same practitioner for the same patient on the same date of service. 
Claims processing contractors must adopt edits to assure that Type I add-on codes are never paid unless a listed 
primary procedure code is also paid. Therefore, we decided that the Plan does not have to pay for the surgical 
services (CPT code(s): 63047-AS, 63048-AS, 61783-AS and 63047) provided on July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 24, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement in place which indicates that these services are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 24, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the thorax (71260) and 
a computed tomography (CT) of the abdomen and pelvis (74177) to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve a CT scan of the thorax, abdomen, and pelvis. You say that you have 
stomach pain, and you would like to check to see why the pain has become an extra problem. You say you need 
to be approved for this visit because this will tell if you have stomach cancer or not. The Plan denied your 
request. The Plan says the requested provider is not contracted in your network. There are providers available 
in your network who can care for you. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomography (CT) of the thorax (71260) and a computed tomography (CT) of the abdomen and 
pelvis (74177) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided on June 6, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and is 
supported in the medical record. 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 (81479) provided on June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 5, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these lab services were medically necessary and 
should be paid. The Plan denied your request. The Plan says the mass spectrometry service (code 83789) is not 
covered.  The Plan also says that the drug testing service (code G0480) is not covered because your lab is not 
contracted with the Plan and the ordering provider is also not a contracted provider with the Plan. 
 In relation to code G0480, 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 provider in this case is not a network provider with the Plan. 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/service. 
 
In relation to code 83789, Medicare rules say that providers performing validity testing on urine specimens 
utilized for drug testing should not separately bill the validity testing. As a result, we find that the testing 
described by code 83789 is not separately payable. Therefore, we decided that the Plan does not have to pay for 
lab services provided on July 5, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0576 and 
half leg sleeves rendered on March 2, 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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (PCD) coded E0576 and half leg sleeves rendered on March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466) and additional item (E1399). 
 
You asked the Plan to pre-approve a home ventilator and additional item. The Plan denied your request. The 
Plan says the request for a home mechanical ventilator set in targeted tidal volume, volume-assured pressure 
support (TTV-VAPS) mode with Auto-expiratory-positive airway pressure (EPAP) that could be delivered by 
bilevel positive airway pressure (BiPAP) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
  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 home ventilator and additional item. 
Our reviewer says that the enrollee does not meet the coverage criteria for a home ventilator and additional 
item. Our physician reviewer found the provided medical records document chronic respiratory failure 
consequent to chronic obstructive pulmonary disease. Our reviewer found that the provided records document 
that the home ventilator is being requested for use in targeted tidal volume, volume-assured pressure support 
(TTV-VAPS) mode with auto-expiratory-positive airway pressure (EPAP) which could be provided by a 
BiPAP device with average volume assured pressure support (AVAPS) and a back-up rate. Our physician 
reviewer also found that as stated in the Local Coverage Determination (L33800), Claims for ventilators used 
to provide continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in 
this respiratory assist device (RAD) policy will be denied as not reasonable and 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 a home ventilator and additional item have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a home ventilator (E0466) and additional item (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency and peripheral nerve ablation. 
 
You asked the Plan to pre-approve radiofrequency and peripheral nerve ablation. You say that the records 
provided support the need for the requested services. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that repeat thermal facet joint RFA at the same anatomic 
site is considered medically reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six months or at least 50% consistent improvement in the ability to perform 
previously painful movements and ADLs as compared to baseline measurement using the same scale. 
 
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 radiofrequency and peripheral nerve 
ablation. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
records show that the enrollee had improvement in pain for only 4 months. Therefore, the request is deemed 
not medically reasonable and 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 radiofrequency and peripheral nerve ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiofrequency and peripheral nerve ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement in place which indicates that these services are included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 6, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
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 code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is on comfort care and has no daily skilled nursing needs. Daily skilled 
therapy is not indicated. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 64999 provided on August 11, 2022. 
 
You asked the Plan to pay for procedure code 64999. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules 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 provided the procedure code which the Plan states 
should be billed, and the Plan has not support their denial with a rule based on Medicare criteria. Therefore, we 
decided that the Plan has to pay for procedure code 64999 provided on August 11, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 17, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this service was medically necessary. 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 March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid; respiratory 
virus 3-5 targets (87631) provided on February 14, 2022. 
 
You asked the Plan to pay for the respiratory panel of 3-5 targets. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this respiratory panel was unbundled from other 
respiratory pathogen testing. respiratory pathogen panel testing of 6 or more pathogens is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed 
in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. This respiratory panel was billed with additional respiratory pathogen 
codes equaling six or greater pathogens. Based on this information, we decided that Medicare rules for 
coverage of the respiratory panel of 3-5 targets have not been met. Therefore, we decided that the Plan does not 
have to pay for the infectious agent detection by nucleic acid; respiratory virus 3-5 targets (87631) provided on 
February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive drug testing billed with code 80307 for 
September 14, 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 procedure code 80307 is not supported. 
 
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 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service. 
 
We find that CPT code 80307 is not supported in the medical record. Specifically, there is no documentation of 
presumptive drug test results. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive drug 
testing billed with code 80307 for September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on May 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was necessary and is 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 (G0483) provided on May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88365 and 88377 
billed for date of service February 25, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, 88365 and 88377. You say that these 
services were necessary and were reported correctly. The Plan denied your request. The Plan says this code is 
included in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
88365 and 88377. This means there is both a professional and technical component for the CPT code(s). In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
88341, 88342, 88360, 88365 and 88377. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341, 88342, 88360, 88365 and 88377 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88365 and 88377 billed for date 
of service February 25, 2022.