Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of codes 95907, 
95886, and 95937, is not supported. Our reviewer found that there is no medical documentation that supports 
these codes billed for the professional component (-26 modifier). 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services provided on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on February 9, 2022. 
 
You asked the Plan to pay for the services provided. You say that the claim denied in error. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 
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 a screening colonoscopy was converted to a diagnostic colonoscopy. The claim does not show that 
the anesthesia services were billed as required. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the anesthesia services provided on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided on 
October 5, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory service. You say that the SelectMDx test can help predict the 
likelihood that the prostate cancer will be found by a biopsy. 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 unlisted molecular pathology procedure (81479) 
provided on October 5, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service January 1, 
2022, to January 28, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this is a payable code. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service January 1, 2022, to January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a GeneSight Psychotropic Assay test (81479) provided on 
May 31, 2022. 
 
You asked the Plan to pay for genetic testing.. You say that you disagree with the denial. The requested testing 
was medically necessary. The Plan denied your request. The Plan says this test is considered investigational 
and/or experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 We looked at the file and Medicare rules. In the case of MolGen testing, FDA clearance is not a reliable 
standard given the number of laboratories developed tests that currently fall outside of FDA oversight and FDA 
clearance often does not assess clinical utility. Based on this information, we decided that Medicare rules for 
coverage of genetic testing. have not been met. Therefore, we decided that the Plan does not have to pay for a 
GeneSight Psychotropic Assay test (81479) provided on May 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81455) provided on April 12, 2022. 
 
You asked the Plan to pay for procedure code 81455. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. The rules say that generally laboratory services should be billed with the 
date of specimen collection as the reported date of service; however, there are three exceptions to this rule. The 
rules also 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 has not acknowledged nor addressed the possible 
exceptions to the rule applied in this case. The sample in this case was collected as part of a biopsy procedure 
performed in an outpatient hospital setting, so it is likely that an exception has been met in this case. Therefore, 
we decided that the Plan has to pay for the laboratory services (81455) provided on April 12, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 8, 2021. 
 
You asked the Plan to pay for the services. 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 29, 2021. 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 services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external recharging system (L8689) provided on 
February 1, 2021. 
 
You asked the Plan to pay for the equipment. The Plan denied your request. The Plan says proof of delivery 
was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery which supports medical necessity for the supplies 
provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the external 
recharging system (L8689) provided on February 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nurse, home health physical therapy 
and home health occupational therapy visits. 
 
You asked the Plan to pre-approve home health skilled nurse, home health physical therapy and home health 
occupational therapy visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nurse, home health 
physical therapy and home health occupational therapy visits. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found in this case, the documentation does not support that the 
enrollee requires additional skilled nursing services or skilled rehabilitation services to provide treatment that is 
medically necessary. The enrollee does not require additional skilled nursing or rehabilitation services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are 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 home health skilled nurse, home health physical therapy and home health 
occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-
approve home health skilled nurse, home health physical therapy and home health occupational therapy visits.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81455) provided on April 14, 2022. 
 
You asked the Plan to pay for procedure code 81455. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. The rules say that generally laboratory services should be billed with the 
date of specimen collection as the reported date of service; however, there are three exceptions to this rule. The 
rules also 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 has not acknowledged nor addressed the possible 
exceptions to the rule applied in this case. The sample in this case was collected as part of a biopsy procedure 
performed in an outpatient hospital setting, so it is likely that an exception has been met in this case. Therefore, 
we decided that the Plan has to pay for the laboratory services (81455) provided on April 14, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 23, 
2022, to May 20, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this is a per diem code. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service April 23, 2022, to May 20, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pre-approve 6 additional transportation trips. 
 
You asked the Plan to pre-approve 6 additional trips. You say that you need additional transportation for 
upcoming appointments. The Plan denied your request. The Plan says that the maximum benefit has been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan says that extra one-way transportation trips cannot be approved. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of additional transportation have been met. Specifically, the Plan has shown 
only 14 dates of service that trips were used and paid for. This means that you have 6 remaining trips of the 20 
one-way trips allowed per year. Therefore, we decided that the Plan has to pre-approve 6 additional 
transportation trips.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 47425 billed for date of service April 4, 
2022. 
 
You asked the Plan to pay for procedure code 47425. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 47425 is bundled into payment for code 47760. 
 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 47425 
is a column II code to column I code 47760. 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 47425 billed for date of service April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0480. 
 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 83789 
is a column II code to column I code G0480. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. 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 83789 billed for date of service May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
November 29, 2021. 
 
You asked the Plan to pay for code 83789. You say that this service was medically necessary. The Plan denied 
your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed with code 83789 for date of service November 29, 2021.
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 July 
23, 2021, to August 2, 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 in this case.  
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 872 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITHOUT MCC). 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 there was no clinical 
or laboratory evidence of sepsis. The review has determined that the records support the use of DRG 690 in this 
case. The records do not support A41.51 - Sepsis due to Escherichia coli [E. coli].  
 
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 July 23, 2021, to August 2, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion, hydration provided on  February 9, 2022. 
 
You asked the Plan to pay for intravenous infusion, hydration. The Plan denied your request. The Plan says the 
medical record does not document a diagnosis medical necessity for these services. The fluid used to 
administer the drug is incidental hydration and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that fluid used to administer drug(s) is incidental 
hydration and not hydration therapy and are considered not medically reasonable and necessary. 
 
We looked at the file and Medicare rules. Medicare says that fluid used to administer drug(s) is incidental 
hydration and not hydration therapy and are considered not medically reasonable and necessary. Therefore, we 
decided that the Plan does not have to pay for intravenous infusion, hydration provided on February 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says the benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from March 12, 2022 to June 
30, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81307, 81406, 81479) provided on January 
12, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the requested lab is a non-network provider who does not work with the enrollees 
health plan, and the enrollee was referred by a provider, who also does not work with the enrollees plan. The 
enrollee's primary care physician did not refer for services. The Plan requires utilization of network providers 
when possible and available and requires authorization for certain services. 
 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 genetic testing (81307, 81406, 81479) provided on 
January 12, 2022, by an out-of-network (OON) provider.