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

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 0242U) provided on 
September 1, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code 0242U (1 
Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on August 26, 2021, and received by the lab on August 28, 2021; therefore, the billed 
code cannot be verified. It is noted multiple attempts were made to obtain additional information from the 
provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code 
0242U) provided on September 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or 
skilled therapy services (or a combination of these services) on a "daily basis" in a SNF.  As a practical matter 
this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
The enrollee's needs are currently being met in the IRF. The documentation does not reveal that the enrollee 
requires a transfer to a SNF. 
 
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 skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) level of care. 
 
You asked the Plan to pre-approve the SNF level of care. You say that you would like to receive physical 
therapy so you can get your strength back and get out of bed. The Plan denied your request. The Plan says you 
do not meet the criteria for the SNF level of care. 
 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 SNF level of care. Our reviewer 
says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have 
daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the SNF level of care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a skilled nursing facility (SNF) level of care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a breast procedure (19499) provided on September 2, 2021. 
 
You asked the Plan to pay for a breast procedure. You say that this service is documented in the records. The 
Plan denied your request. The Plan says this code 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. The rules also say that when reporting an 
"unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative description in claim 
form item 19 if a coherent description can be given within the confines of that box. Otherwise, an attachment 
shall be submitted with the claim.  
In this case, the CPT Code Manual definition of code 19499 is unlisted procedure, breast. 
 
We find that CPT code 19499 is not supported in the medical record. Specifically, this is an unlisted procedure 
code that was not reported with a narrative description of the code in item 19 of the claim or in an attachment. 
Based on this information, we decided that Medicare rules for coverage of a breast procedure have not been 
met. Therefore, we decided that the Plan does not have to pay for a breast procedure (19499) provided on 
September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on June 14, 2021. 
 
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 codes 82542 and 83789 are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
 
 
 The provider submitted a claim for procedure codes 82542 (column chromatography), 83789 (mass 
spectrometry), and 80307 (presumptive drug testing). Codes 82542 and 83789 are column II codes with a 
modifier indicator of 1 when billed with column I code 80307. The column II codes were not billed with an 
appropriate modifier to allow for separate payment. The file does not support the -59 modifier as a separate and 
distinct procedural service. Therefore, we decided that the Plan does not have to pay for the testing services 
rendered on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hyperbaric oxygen therapy services provided on May 17, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the documentation supports the billed code. 
The Plan denied your request. The Plan says the billed service cannot be verified. 
 
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 G0277 is hyperbaric oxygen under pressure, full body 
chamber, per 30-minute interval. We find that 4 units of CPT code G0277 is not supported in the medical 
record. Specifically, the medical records show that the enrollee received 90 minutes of hyperbaric oxygen 
therapy.  Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the hyperbaric oxygen therapy services 
provided on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 81479) provided on June 
2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code 81479 (1 unit) 
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on May 26, 2021, and received by the lab on May 27, 2021. Of note, the patient resides 
in Ohio and the billing laboratory is located in Illinois; therefore, the billed code cannot be verified. It is noted 
multiple attempts were made to obtain additional information from the provider. Therefore, the validity and 
accuracy of the claim cannot be verified. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code 81479) provided on June 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
September 27, 2021, to September 30, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you did not have a bed for 
the entire stay and disagree with the copayment. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $280 
copayment for days 1-6 for inpatient hospital care.  
 
You have been asked to pay $560, which is less than the total copayment for inpatient hospital care. Inpatient 
hospital care falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital care provided from September 27, 2021, to September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genesight Psychotropic panel provided on September 9, 
2021. 
 
You asked the Plan to pay for the Genesight Psychotropic panel. You say that this testing is covered by the 
Medicare contractor that services Ohio and cannot be denied by the Plan. The Plan denied your request. The 
Plan says this testing is not supported as medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomic testing, such as Genesight 
Psychotropic, does not have sufficient evidence to conclude it is more effective than standard prescribing 
protocols.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Genesight Psychotropic panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the Genesight Psychotropic panel provided on September 9, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for a comprehensive hearing test provided on November 
2, 2021. 
 
You asked the Plan to reduce the copayment for a comprehensive hearing test. You say that per the EOC you 
should have a $40 copayment for a diagnostic hearing and balance evaluation from a specialty provider. The 
Plan denied your request. The Plan says that you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $40 copayment for a diagnostic hearing evaluation from a 
specialty provider.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms 
that there are different cost sharing amounts for different types of diagnostic hearing evaluations 
 
The Plan says you must pay a $150 copayment for a comprehensive hearing test. The record shows the test you 
received is a diagnostic hearing evaluation with a specialty provider. Based on the Plan contract, you cannot be 
asked to pay more than a $40 copayment for a comprehensive hearing test. Therefore, we decided that the Plan 
has to reduce the copayment for a comprehensive hearing test provided on November 2, 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 the laboratory services (CPT code 81479) provided on June 
8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the 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 laboratory services have not been met. CPT code 81479 
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an outpatient hospital POS 22; therefore, the billed code cannot be verified. 
It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we 
decided that the Plan does not have to pay for the laboratory services (CPT code 81479) provided on June 8, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical preparation (15004) and muscle, myocutaneous, 
or fasciocutaneous flap (15733) provided on August 30, 2021. 
 
You asked the Plan to pay for the surgical preparation (15004) and muscle, myocutaneous, or fasciocutaneous 
flap (15733). You say that the medical records support all the codes and should be reviewed. The Plan denied 
your request. The Plan says the services are not supported by the medical records. 
 
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 15004 is surgical preparation or creation of recipient site 
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 
sq cm or 1% of body area of infants and children.   The CPT Code Manual definition of code 15733 is muscle, myocutaneous, or fasciocutaneous flap; head and 
neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, 
levator scapulae). 
 
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 surgical preparation (15004) and muscle, myocutaneous, 
or fasciocutaneous flap (15733). Our reviewer says that the documentation submitted was reviewed and does 
not meet the criteria for coverage. Our reviewer found that the operative report does not include documentation 
of surgical preparation or creation of recipient site, the operative report describes the wound was irrigated. This 
description does not support surgical preparation or creation of recipient site. Therefore, CPT code 15004 
cannot be verified. The operative report does not support the criteria in the code description for CPT code 
15733. The operative report describes a nasolabial flap with preservation of angular artery and vein. This is the 
incorrect code to report for this procedure, as the angular artery and vein would not be included in this 
procedure code. 
 
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 surgical preparation (15004) and muscle, myocutaneous, or fasciocutaneous 
flap (15733) have not been met. Therefore, we decided that the Plan does not have to pay for the surgical 
preparation (15004) and muscle, myocutaneous, or fasciocutaneous flap (15733) provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collagen dressing (A6021) provided on August 2, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for collagen dressing. You say that you have a contract with the nursing home to 
send wound care supplies to all the patients with Medicare Part B benefits and they could not have gotten the 
supplies from any other vendor. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan, and they have also determined that these services are not urgent or emergent, nor were 
they approved in advance. 
 
 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 in this case is not a network provider 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 collagen dressing (A6021) provided on August 2, 
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81210, 81235, 81275, 
81276, 81295, 81298, 81301, 81317, 81401, 81194 and 81309) provided on May 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 81210, 
81235, 81275, 81276, 81295, 81298, 81301, 81317, 81401, 81194 and 81309, remains not supported. The place 
of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained 
in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on May 
5, 2021, and received by the lab on May 12, 2021, however, the billed date of service is May 28, 2021; 
therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional 
information from the provider. 
 
Review of the available records presented for an appeal of molecular genetic pathology testing has been 
completed. After reassessing the entire situation, the result is that the initial denial is upheld. As CGP testing is 
not defined as a targeted panel by MolDX; and is a test not currently satisfactorily described by any existing 
CPT code; to report a CGP testing is not defined as a targeted panel by MolDX; and it is a test not currently 
satisfactorily described by any existing CPT code; to report a CGP, service providers should use 1-unit only 
of CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved 
DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes, 
or other unlisted code. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(CPT code(s): 81210, 81235, 81275, 81276, 81295, 81298, 81301, 81317, 81401, 81194 and 81309) provided 
on May 28, 2021.