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

 
We decided that the Plan does not have to pay for lab services provided on July 13, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83718, 83721, 84436, and 85007 billed for 
date of service March 23, 2021. 
 
You asked the Plan to pay for procedure codes 83718, 83721, 84436, and 85007. The Plan denied your request. 
The Plan says payment for codes 83718, 83721, 84436, and 85007 is bundled.  
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 codes 
83718 and 83721 are column II codes to column I code 80061. We have also confirmed that code 84436 is a 
column II code to column I code 84439, and that code 85007 is a column II code to column I code 85025. 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 codes 83718, 83721, 84436, and 85007 billed for date of service March 23, 2021.
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 June 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. 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 June 15, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Decipher prostate cancer genetic testing assay provided on June 2, 
2022. 
 
You asked the Plan to pay for the Decipher genetic testing. You say that the testing at issue is covered by 
Medicare for patients such as this one. The Plan denied your request. The Plan says that this testing is not 
found to be medically reasoanble and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Decipher genetic testing may be covered for patients 
with prostate cancer who meet the criteria listed in the LCD.  
 
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 Decipher genetic testing. Our reviewer 
says that the documentation supports that the criteria for the rendered testing have been met. Our physician 
reviewer found the enrollee is a 67-year-old with Gleason's grade 3+4 adenocarcinoma of the prostate with 
baseline prostate-specific antigen (PSA) of 7.9ng/mL. He underwent robotic prostatectomy and has had urinary 
incontinence since the surgery. His urologist is considering treating him with radiation.  
 
Decipher testing is medically necessary in this case. The records show that the enrollee is eligible for 
observation post-prostatectomy yet would be eligible for the addition of post-operative adjuvant radiotherapy 
as is required by the LCD. 
 
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 Decipher genetic testing have been met. Therefore, we decided that the Plan 
has to pay for the Decipher prostate cancer genetic testing assay provided on June 2, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G device (L8702). 
 
You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied 
your request. The Plan says the requested device is not indicated for patients with upper-extremity weakness or 
paresis and is considered experimental and 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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro is not the standard of care for this enrollee's condition or in widespread use for this 
enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the 
MyoPro Orthosis will improve the long-term outcomes for this enrollee. There is insufficient evidence in the 
literature that this device will increase participation in bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G device (L8702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation and report rendered on August 
30, 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. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. The file shows that procedure code 85060 was not performed for a 
hospital inpatient. 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 blood smear interpretation 
and report rendered on August 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 10, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was medically necessary. 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 October 10, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on March 24, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
the enrollee met medical necessity and you would like this claim to be considered for payment. The Plan 
denied your request. The Plan says this service is not covered. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 non-emergency ambulance 
transportation and ground mileage. Our reviewer says that transportation by ambulance from the hospital to the 
enrollees residence was not medically necessary. Our physician reviewer found the enrollee did not require the 
expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport. While the enrollee is noted to have been bedbound, transportation could have been provided by other 
means (i.e., stretcher van). Our reviewer also found that a prudent layperson would not believe that immediate 
medical attention was required for someone who was being discharged from the hospital.  
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 non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on March 24, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 7, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 76641 is1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88360 and 88381 billed for date of service 
February 24, 2022. 
 You asked the Plan to pay for procedure codes 88360 and 88381. You say that you disagree with the Plan's 
denial. 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 codes 88360 and 88381. This 
means there is both a professional and technical component for the CPT codes. In this case, an appropriate 
modifier to indicate the professional component has not been billed with CPT codes 88360 and 88381. Based 
on this information, we decided that Medicare rules for coverage of procedure code 88360 and 88381 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 88360 and 88381 billed 
for date of service February 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 27507 billed for July 1, 2022. 
 
You asked the Plan to pay for code 27507. The Plan denied your request. The Plan says the billed 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. 
 
In this case, the CPT Code Manual definition of code 27507 is "Open treatment of femoral shaft fracture with 
plate/screws, with or without cerclage". 
 
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 code 27507. Our reviewer says that the use of code 27507 is 
not supported by the records provided. Our reviewer found that the operative report does not include enough 
documentation to confirm open treatment of femoral shaft fracture with plate/screws was performed. The 
operative report documents, "Having exposed the femoral shaft fracture multiple cerclage cables were utilized 
to secure the reduction of this as well as an additional prophylactic sulcal cerclage distally to prevent fracture 
propagation during reaming. Once the femoral fracture was fixed the hip was dislocated". In this case, the code description of CPT 27507 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 27507 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 27507 billed for July 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the auditory osseointegrated device, external sound 
processor, excludes transducer/actuator, replacement only, each (L8691) and auditory osseointegrated device, 
transducer/actuator, replacement only, each (L8694) provided on September 12, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the auditory device. You say that you did check to request a prior authorization 
and was informed that no authorization was needed. Please reprocess your claim per CMS guidelines due to the 
error that happened on the Plan's side as you have done your due diligence to ensure you had all prior 
documentation. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
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 the auditory osseointegrated device, external 
sound processor, excludes transducer/actuator, replacement only, each (L8691) and auditory osseointegrated 
device, transducer/actuator, replacement only, each (L8694) provided on September 12, 2022, by an out-of-
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99231) provided from June 22, 
2022, to June 27, 2022. 
 You asked the Plan to pay for hospital care. You say that these services are supported as billed. The Plan 
denied your request. The Plan says the payment for these services is included in the 90-day global surgery 
package for code 31613, which was provided to this enrollee on May 13, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for procedures 
with a global surgery period includes payment for following services related to the surgery when furnished by 
the physician who performs the surgery. 
 
We looked at the file and Medicare rules. The services at issue were performed within the 90-day global 
surgery period of code 31613. The services at issue were not billed with a modifier to show that these services 
were not related to the enrollee's recent procedure. Based on this information, we decided that Medicare rules 
for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for 
subsequent hospital care (99231) provided from June 22, 2022, to June 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on June 20, 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 codes 26236 and 20103 are 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 26236 is partial excision (craterization, saucerization, or 
diaphysectomy) bone (eg, osteomyelitis); distal phalanx of finger. The definition of code 20103 is exploration 
of penetrating wound (separate procedure); extremity. 
 
We find that CPT codes 26236 and 20103 are not supported in the medical record. Specifically, the operative 
report does not include documentation of a partial excision of a distal phalanx finger bone to support code 
26236. The operative report does not include documentation of exploration of a penetrating wound for an 
extremity to support code 20103. 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 surgical 
services rendered on June 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service September 6, 
2022. 
 You asked the Plan to pay for procedure code 76700. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 76700 is bundled into payment for code 93976. 
 
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 76700 
is a column II code to column I code 93976. 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 76700 billed for date of service September 6, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75736, 75774, and 99153 billed for date of 
service June 8, 2022. 
 
You asked the Plan to pay for procedure codes 75736, 75774, and 99153. You say that these services were 
billed correctly. The Plan denied your request. The Plan says payment for codes 75736 and 75774 is bundled 
into payment for code 37243 and code 99153 is not payable in a facility setting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that the OPPS 
recognizes that CPT code 99153 is a PE only code and that PE are not payable to the physician for services 
provided in the facility setting. In this case, we have confirmed that codes 75736 and 75774 are column II 
codes to column I code 37243. 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. We also find that payment for CPT 
code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 
when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for procedure 
codes 75736, 75774, and 99153 billed for date of service June 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, 
respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and 
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets (87633) provided on October 9, 
2021. 
 
You asked the Plan to pay for detection test by nucleic acid for multiple types of respiratory virus, multiple 
types or subtypes, 12-25 targets. You say that this testing was medically necessary. The Plan denied your 
request. The Plan says this testing 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. In this case the requested testing is for greater than 5 respiratory 
pathogens. Based on this information, we decided that Medicare rules for coverage of detection test by nucleic 
acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets have not been met. 
Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid 
(DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, 
parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when 
performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets (87633) 
provided on October 9, 2021.