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

 
We decided that the Plan has to pay for procedure codes 87150, 87481, 87500, 87641, 87651, 87653, 87798 
and 87801. We decided that the Plan does not have to pay for procedure code 87640.  
 
You asked the Plan to pay for procedure codes 87640, 87150, 87481, 87500, 87641, 87651, 87653, 87798 and 
87801 billed for date of service July 22, 2022. You say that these services were necessary and are supported as 
billed. The Plan says that the payment for code 87640 is bundled into the payment for code 87641. 
 
We decided that the Plan has to pay for procedure codes 87150, 87481, 87500, 87641, 87651, 87653, 
87798 and 87801.  
 
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 did not provide a denial rationale for these codes, nor did 
the Plan provide a valid reason that these codes are exempt from the Medicare Managed Care Reconsideration 
appeal process. Therefore, we decided that the Plan has to pay for procedure codes 87150, 87481, 87500, 
87641, 87651, 87653, 87798 and 87801.  
 
We also decided that the Plan does not have to pay for procedure code 87640. 
 
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 87640 
is a column II code to column I code 87641. 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 87640. 
 
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 laboratory services (0089U, 81345) provided on May 24, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network laboratory services. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says out-of-network care is 
covered only in certain limited circumstances which have not been met in this case. These services were not 
urgent or emergent and they were not referred by a network provider. In addition, the payment for code 81345 
would be bundled into the payment for 0089U and is not separately payable in this case. 
 
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/referred 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 laboratory services (0089U, 81345) 
provided on May 24, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 1, 
2022. 
 
You asked the Plan to pay for SNF care. You say that the admission and care were medically necessary for the 
enrollee. The Plan denied your request. The Plan says the SNF admission was 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 pay for SNF care. Our reviewer says that the SNF 
care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
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 SNF care have not been met. Specifically, the provided documentation from the 
enrollee's inpatient hospital stay is not sufficient to support that skilled nursing facility (SNF) services were 
necessary for the enrollee. The file shows that the Plan requested medical records from the SNF stay, but none 
were received. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care 
provided from April 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a brain imaging, positron emission tomography (PET); 
metabolic evaluation (78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the medical records provided do not indicate that the enrollee meets the 
diagnostic criteria of both Alzheimer's disease and frontotemporal dementia. There is no indication that the 
exam is being requested in the context of a clinical trial. The request does not meet the Medicare or health plan 
coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 pre-approve a PET scan of the brain. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the applicable NCD states that a 
PET/CT may be covered when a patient meets the diagnostic criteria of both Alzheimer's disease and 
frontotemporal dementia. The records provided for review indicate that the enrollee has a neurocognitive 
disorder but does not indicate a suspicion for either AD or FTD--let alone both diagnoses. In such a setting the 
request would not meet the initial requirement of the NCD for coverage of this service. Therefore, this would 
not be 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 PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a brain imaging, positron emission tomography (PET); metabolic evaluation 
(78608).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says settings 
that could be provided with a BiPAP are 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 the requested services. Our physician 
reviewer found that you have COPD, with a recent hospitalization. There are no pulmonary function tests to 
confirm COPD, but you have reportedly had repeated hospitalizations in the past, including intubation. An 
arterial blood gas (ABG) during the most recent hospitalization is consistent with acute on chronic hypercarbic 
respiratory failure. You may benefit from BiPAP during sleep as an outpatient.  However, Medicare does not 
cover a home ventilator when used as BiPAP. Therefore, the request is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72190, 71045 and 93010 billed for date of 
service January 18, 2022. 
 
You asked the Plan to pay for procedure codes 72190, 71045 and 93010. You say that these services were 
medically necessary and appropriate. The Plan denied your request. The Plan says these services cannot be 
verified as billed, as the patient's name is missing from the medical records for these services. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure codes 72190, 71045 and 
93010 have been met. Specifically, the name included on the medical records provided is "trauma patient". 
Without the name of the patient receiving services, this claim cannot be verified as billed. Therefore, we 
decided that the Plan does not have to pay for procedure codes 72190, 71045 and 93010 billed for date of 
service January 18, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (U0003) provided January 27, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says Original Medicare is liable for payment for these services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for lab services (U0003) provided January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4253 billed for date of service June 14, 
2021. 
 
You asked the Plan to pay for procedure code A4253. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code A4253 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 A4253 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4253 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4253 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4253 billed for date of service June 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (CPT code(s): 63012, 63011, 22612 and 
22614) provided on June 6, 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 supported by the 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. 
 
Per the operative report the laminectomy with removal of abnormal facets and/or pars inter-articularis with 
decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) was 
performed at the same level as the arthrodesis procedure. NCCI Policy Manual states, "The edit indicates that 
the 2 procedures shall not be reported together at the same anatomic site (spinal level) at the same patient 
encounter. A physician shall not use modifiers 59 or -X{ES} to bypass this edit unless the 2 procedures are 
performed at separate anatomic sites (i.e., different spinal levels) or separate patient encounters on the same 
date of service." In addition, per coding guidelines, Lumbar decompression codes are driven by the diagnosis as 
opposed to the technique involved. The body of the operative report does not contain a description of lumbar 
laminectomy for treatment of a spondylolisthesis diagnosis.  Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services (CPT code(s): 63012, 63011, 22612 and 22614) provided on June 
6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill 
or critically injured patient; first 30-74 minutes (CPT code 99291) provided from January 18, 2022, through 
January 21, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the 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. 
 
CPT code 99291 remains not supported. The documentation submitted did not support a critical care visit of 
30-74 minutes was performed on January 18, 2022, and January 21, 2022. The documentation does not include 
the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the services have 
not been met. Therefore, we decided that the Plan does not have to pay for critical care, evaluation and 
management of the critically ill or critically injured patient; first 30-74 minutes (CPT code 99291) provided 
from January 18, 2022, through January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 20, 2022, billed with 
codes 81226 and 81225. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported as billed. 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 
July 20, 2022, billed with codes 81226 and 81225.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy. 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 ultrasound guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found generally the response from radiation continues even after it is 
completed. Radiation often causes a skin reaction, including desquamation. There is no evidence basis to use 
ultrasound findings half-way through or at the end of treatment to modify the treatment plan. Even if that was 
the intent, this would be billed as a simulation as opposed to image-guidance (neither of which are standard of 
generally considered necessary outside of exceptional circumstance for which the plan needs to be modified). 
Image-guided radiation therapy (IGRT) as described in the letter of appeal would not be furnished in 
accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology procedures provided to the enrollee on 
July 2, 2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no personal or family history of cardiomyopathy. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has no personal or family history of cardiomyopathy. The review has determined that 
the services at issue in this case were not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for molecular pathology procedures provided to the enrollee on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician stand by services coded 99360 provided on July 1, 
2022. 
 
You asked the Plan to pay for physician stand by services. 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 99360 is standby service, requiring prolonged attendance, 
each 30 minutes (eg, operative standby, standby for frozen section, for cesarean/high risk delivery, for 
monitoring EEG). 
 
We find that CPT code 99360 is not supported in the medical record. Specifically, stand by services are not 
payable to physicians. Payment for standby services is included in the Part A payment to the facility. This 
means that these services are not separately payable. Based on this information, we decided that Medicare rules 
for coverage of physician stand by services have not been met. Therefore, we decided that the Plan does not 
have to pay for physician stand by services coded 99360 provided on July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided on June 1, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (0037U) provided on 
June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight psychotopic testing provided on November 9, 
2021. 
 
You asked the Plan to pay for the GeneSight psychotopic testing. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services rendered are not supported. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The documentation shows that the order for this testing was the same order previously received. The form was 
not signed but with a typed name. There were no credentials or NPI on the form. This means the ordering for 
this testing was considered incomplete.  With an incomplete order for the GeneSight psychotopic testing, this 
means that there is no documentation to support that the testing rendered was not requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the GeneSight psychotopic testing provided on November 9, 2021.