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

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on March 30, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says this service is not supported 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 G0483 is drug test(s), definitive, 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records support that 15 
drug classes were tested in this case. Another code would report this service more accurately. Based on this 
information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we 
decided that the Plan does not have to pay for definitive drug testing (G0483) provided on March 30, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 99285. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99285 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99285 billed for date of service September 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 27, 2022, to 
July 28, 2022 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 27, 2022, to July 28, 
2022
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the take home methadone supply billed with code G2078 for 
June 19, 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 were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that services rendered to a patient who is a registered 
inpatient shall report the inpatient hospital POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claim was not billed with the POS code 21. Therefore, we decided that the Plan 
does not have to pay for the take home methadone supply billed with code G2078 for June 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (81439) 
provided on October 9, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening testing. You say that this testing 
was medically necessary. The Plan denied your request. The Plan says this service is not covered under 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: code 80061 (Lipid panel) which includes codes: 82465 (Cholesterol, serum 
or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol), and/or 84478 
(Triglycerides). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the cardiovascular screening/risk assessment panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the cardiac risk assessment genetic screening testing (81439) provided on 
October 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on September 20, 2022. 
 
You asked the Plan to pay for procedure code J3490. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is 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 CPT code. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this code was included in the 
global surgery period of procedure code 20552 that was billed for the same date of service. Based on this 
information, we decided that Medicare rules for coverage of procedure code J3490 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code J3490 provided on September 20, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for monitoring services (95938, 95870 and G0453) provided on 
November 24, 2021. You asked the Plan to pay for monitoring services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says codes 95870 and 95938 were not billed with an appropriate 
diagnosis code. Code G0453 was not billed with a supported/approved primary procedure. 
 
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 there are certain 
diagnosis codes which support the medical necessity of codes 95938 and 95870. 
 
We looked at the file and Medicare rules. This claim was billed with diagnosis M54.50, which is not on the list 
of codes which support the medical necessity of either code 95938 or 95870. In addition, we have confirmed 
that code G0453 is an add-on code and has not been billed with an appropriately billed primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for monitoring services (95938, 95870 and G0453) provided on November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 99153 and 92929 provided on April 12, 
2022. 
 
You asked the Plan to pay for procedure codes 99153 and 92929. You say that this service was medically 
necessary. The Plan denied your request. The Plan says these codes are not separately payable. 
 
Medicare rules 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.  
 
We 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. Procedure code 92929 has a status 
indicator of "B" and payment is always bundled with another service. Therefore, we decided that the Plan does 
not have to pay for procedure codes 99153 and 92929 provided on April 12, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Oncology (melanoma), gene expression profiling by RTqPCR, 
PRAME and LINC00518, superficial collection using adhesive patch(es) (0089U) on July 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that this claim remains unpaid for good faith 
services rendered to the enrollee. The Plan denied your request. The Plan says that these services are non-
covered because this is not deemed medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 laboratory services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a history of skin lesion. The provider ordered 
Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collection 
using adhesive patch(es) (0089U). The DermTech Melanoma Test is used to rule out melanoma (with 99% 
accuracy, better than the 83% accuracy of the current biopsy care pathway). The review indicates that the 
items/services at issue in this case are medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have been met. Therefore, we decided that the Plan has 
to pay for the Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, 
superficial collection using adhesive patch(es) (0089U) on July 6, 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 procedure code 71250 billed for date of service November 2, 
2022. 
 You asked the Plan to pay for procedure code 71250. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 71250 is bundled into payment for 
code 71275. 
 
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 71250 
is a column II code to column I code 71275. 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 71250 billed for date of service November 2, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 29, 2022, to 
February 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.   
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 29, 2022, to 
February 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T1023 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code T1023. You say that this patient should have been enrolled in a 
Medicaid plan. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 T1023 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T1023 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code T1023 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T1023 billed for date of service March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (85014, 85018, 80048, 85049, 85025, 85027) 
provided on November 16, 2020. 
 
You asked the Plan to pay for the lab services. You say that you believed that this claim was submitted on time. 
The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until August 16, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the lab services (85014, 85018, 80048, 85049, 85025, 85027) provided on 
November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder monitor test (0013M) provided on August 23, 
2022. 
 
You asked the Plan to pay for the Cxbladder monitor test. You say that this testing was medically necessary. 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder monitor test have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder monitor test (0013M) provided on August 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12002 billed for date of service May 5, 2022. 
 You asked the Plan to pay for procedure code 12002. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 12002 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 12002 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 12002 billed for date of service May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted molecular pathology procedure (81479) 
provided on June 23, 2022. 
 You asked the Plan to pre-approve the unlisted molecular pathology procedure. You say that this service was 
medically necessary. The Plan denied your request. The Plan says this service is not covered when done for 
screening purposes. 
 
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 test at issue in this appeal, the unlisted molecular pathology procedure, is being 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 pre-approve the unlisted molecular pathology procedure (81479) provided on June 
23, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided to the enrollee on July 29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this would be covered under Original Medicare. 
 
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 hospital services provided to the enrollee on July 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0463 billed for date of service June 22, 
2022. 
 
You asked the Plan to pay for procedure code G0463. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code G0463 is bundled into payment for code 96413. 
 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 G0463 
is a column II code to column I code 96413. 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 G0463 billed for date of service June 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11102 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 11102. You say that the patient had separate biopsies so this code 
should be paid. The Plan denied your request. The Plan says payment for code 11102 is bundled into payment 
for code 11104. 
 
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 11102 
is a column II code to column I code 11104 with a modifier indicator of 0. The column II code is therefore not payable. 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 11102 billed for date of service September 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76642, 77065, and G0279 billed for date of 
service August 23, 2022. 
 
You asked the Plan to pay for procedure codes 76642, 77065, and G0279. 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 codes 76642, 77065, and G0279 is 1. The MAI value for these codes is 2. You 
billed 2 units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 76642, 77065, and G0279 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 76642, 77065, and G0279 billed for date of service August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry, interpretation; 16 or more markers (88189) 
provided on February 26, 2022. 
 
You asked the Plan to pay for flow cytometry. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is not covered for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that flow cytometry will only be covered for 
indications listed in the LCD and LCA. 
 
We looked at the file and Medicare rules. In this case the flow cytometry was provided for the enrollees 
diagnosis of cerebral infarction due to thrombosis of unspecified precerebral artery (I63.00). This is not a 
covered diagnosis according to the associated LCD and LCA. Based on this information, we decided that 
Medicare rules for coverage of flow cytometry have not been met. Therefore, we decided that the Plan does not 
have to pay for flow cytometry, interpretation; 16 or more markers (88189) provided on February 26, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a continues glucose monitor (CGM) provided on November 14, 2021. 
 
You asked the Plan to pay for a CGM. You say that a CGM is needed. The Plan denied your request. The Plan 
says that they did not come to a decision in a timely manner. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for a CGM. Our reviewer says that a CGM is 
medically necessary. Our physician reviewer found the enrollee is currently injecting insulin; therefore, the 
medical criteria for a GCM has been met. 
 
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 CGM have been met. Therefore, we decided that the Plan has to pay for a 
continues glucose monitor (CGM) provided on November 14, 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.