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

 
We decided that the Plan has to pay for genetic testing (0037U) provided on May 19, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Next Generation Sequencing is covered when 
medically necessary. 
 
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 genetic testing. Our reviewer says that 
this testing was medically necessary. Our physician reviewer found Foundation One genetic testing is a 
covered service and is FDA approved. National Comprehensive Cancer Network guidelines support the testing 
performed. 
 
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 genetic testing have been met. Therefore, we decided that the Plan has to 
pay for genetic testing (0037U) provided on 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 8, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are 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 provided on July 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care services provided from March 15, 2021, to 
April 7, 2021. 
 
You asked the Plan to pay for home health care services. The Plan denied your request. The Plan says the RAP 
was not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that a RAP must be submitted within 5 days of the start of care 
date for home health services. RAPs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 15, 2021. The RAP was not received by the Plan until July 27, 2021. 
As more than 30 days passed between the timely filing date and the RAP receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health care services provided 
from March 15, 2021, to April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (10140) provided on May 7, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 14, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the surgical services have not been met. Therefore, 
we decided that the Plan does not have to pay for surgical services (10140) provided on May 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4556, & A4630 billed for date of service 
May 19, 2022. 
 
You asked the Plan to pay for procedure code A4556, & A4630. You say that this service should be covered. 
The Plan denied your request. The Plan says procedure code A4556, & A4630 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 codes A4556, & A4630 have a status indicator of P on the Physician Fee Schedule. 
This means that procedure code A4556, & A4630 is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure code A4556, & A4630 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes A4556, & A4630 billed for date of service May 
19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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 provided on February 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need the care and that it could endanger your 
health without it. The Plan denied your request. The Plan says an IRF admission is not medically necessary, 
and you can safely get the care you need in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0483) provided on September 27, 2021. 
 
You asked the Plan to pay for drug testing. You say that this test was medically necessary and is supported as 
billed. The Plan denied your request. The Plan says that the records provided only support that 12 drug classes 
were tested in this case; therefore, the code billed 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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers, 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records provided show that 
22 or more drug classes were tested in this case, including amphetamines, barbiturates, benzodiazepines, 
buprenorphine, cannabinoids (natural), cannabinoids (synthetic), cocaine, fentanyls, gabapentin (non-blood), 
heroin metabolite, methadone, methylenedioxyamphetamines, methylphenidate, opiates, opioids and opiate 
analogs, oxycodone, phencyclidine, pregabalin, sedative hypnotics (non-benzodiazepines), skeletal muscle 
relaxants, stimulants (synthetic), tapentadol and tramadol. Based on this information, we decided that Medicare 
rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug 
testing (G0483) provided on September 27, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report 
rendered on April 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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 18, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report 
rendered on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the technical component (TC) of intraoperative 
neuromonitoring (IONM) services provided on March 21, 2022. 
 
You asked the Plan to pay for the TC of the IONM services. You say that the hospital cannot bill for these 
services because you provide the equipment and the technician. You must be paid directly for these services. 
The Plan denied your request. The Plan says payment for this must be requested from the hospital. 
 
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
Although these services may be appropriate, payment for them is made to the hospital which must then furnish 
these services either directly or under arrangements. As such, separate Medicare payment cannot be made for 
the services at issue. Therefore, we decided that the Plan does not have to pay for the technical component (TC) 
of intraoperative neuromonitoring (IONM) services provided on March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM is necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 medical records provided do not document that the enrollee has 
to make frequent adjustments to their insulin dosage based on blood glucose meters (BGM) or CGM testing. 
Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the CGM and supplies.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99283 provided on September 8, 2021. 
 
You asked the Plan to pay for code 99283. 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. 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 99283 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: An expanded problem focused history; 
An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate severity. 
 
 
 
 We find that CPT code 99283 is not supported in the medical record. Specifically, this evaluation and 
management service is not payable for this specialty or provider type billed. Based on this information, we 
decided that Medicare rules for coverage of code 99283 have not been met. Therefore, we decided that the Plan 
does not have to pay for code 99283 provided on September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee cannot fully participate in or benefit from intensive therapy. She is 
deconditioned and does not require frequent input from a physiatrist to regain function. Her rehabilitation needs are consistent with those of many patients post-acute needs are routinely and satisfactorily addressed at a level 
of care other than an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 20, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 9, 2022, billed with 
codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194 and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 9, 2022, billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 
81401, 81194 and 81309.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from April 24, 2022, to 
May 23, 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 NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 24, 2022. The NOA was not received by the Plan until August 27, 
2021. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from April 24, 2022, to May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 9, 2021, to December 13, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated.  
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 871. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented with congestion, cough, and shortness of breath and was diagnosed with pneumonia 
for which he was treated with antibiotics and IV fluids. He had a fever and tachycardia but had normal bilirubin 
and platelet count with stable blood pressure, no evidence of significant hypoxia, and the patient was alert and 
oriented. Also, the Cr was 1.3, however, quickly improved to normal with initial treatment with fluids. These 
findings describe a localized pneumonia without evidence of a significant organ dysfunction due to the 
deregulated host response to the infection and does not meet the Sepsis 3 criteria. The records, therefore, do not 
support that diagnosis code A41.9 (sepsis, unspecified organism) was a reasonable diagnosis for this case, and 
therefore, also do not support DRG 871 (SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS 
WITH MCC).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from December 9, 2021, to December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99203) provided on July 6, 2022. 
 
You asked the Plan to pay for an office visit. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with the most appropriate diagnosis codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Some 
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes indicate 
laterality, specifying whether the condition occurs on the left, right or is bilateral. 
 
The services at issue were billed with the diagnosis codes for right and left side unilateral hip osteoarthritis 
(M16.11 and M16.12) and right and left side unilateral knee osteoarthritis (M17.11 and M17.12). There are 
more appropriate bilateral codes to report the enrollees condition. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an office visit (99203) provided on July 6, 2022.