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

 
We decided that the Plan does not have to pay for procedure codes 87801, 87481, 87640, 87653 and 87798 
billed for date of service October 19, 2021. 
 
You asked the Plan to pay for codes 87801, 87481, 87640, 87653 and 87798. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says code 87801 is 
not supported in the medical record, and the records provided do not support the billing of the other codes or 
the use of the 91 modifier for the services at issue. 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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), amplified probe(s) technique. In addition, we have confirmed that codes 87481, 87640, 87653 and 
87798 are each column II codes to column I code 87801. However, these services have been billed with a 
modifier to bypass this edit. 
 
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 codes 87801, 87481, 87640, 87653 and 87798. Our reviewer 
says that these services are not supported as billed. Our reviewer found that the laboratory report includes 
documentation of a COVID-19 test of a nasal swab. CPT code 87801 represents a lab test for multiple infection 
agents. However, the report documents only COVID-19 testing, and therefore multiple infectious agents cannot 
be verified. Codes 87481, 87640, 87653 and 87798 are also not documented in the laboratory report and cannot 
be verified. In addition, modifier 91 is used when multiple, serial laboratory tests are necessary in the course of 
treating a patient (e.g., repeat blood glucose tests). Modifier 91 is used when a clinical laboratory test must be 
repeated on the same date of service and the results are used to assist in managing the treatment of a patient. 
Repeat clinical diagnostic laboratory tests are not supported by the documentation provided, as only one test 
was performed. Therefore, the modifier used also 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 codes 87801, 87481, 87640, 87653 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87801, 87481, 87640, 87653 and 87798 billed 
for date of service October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tempus Tumor Origin genetic test (81479) billed for date 
of service February 14, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you have provided documentation to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been met because the 
services at issue were billed with an incorrect DOS. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
 
  We looked at the file and Medicare rules. In this case, the services at issue were billed with the DOS the test 
was performed, not the date the specimen was collected. There are no apparent grounds for an exception to the 
rule in this case. 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 Tempus Tumor Origin genetic test 
(81479) billed for date of service February 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve twelve additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records sent do not support the request for treatment. 
 
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 additional visits. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that record does not chart progress toward the goals nor does it provide evidence of unique 
services from a therapist. Chronic pain control does not require on-going therapy and the goal of relieving pain 
after 20 years for a patient with structural spine disease is not appropriate for you. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve twelve additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-spinal bone growth stimulator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a bone growth stimulator is covered when 
specific criteria are met. 
 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has right and left foot 
stress fractures and received standard treatment. A follow-up exam showed improving left foot fracture but 
with non-healing right foot fracture. An x-ray from June 6, 2022 showed the non-healed fracture and repeat x-
ray from September 7, 2022 showed no change in position but had some trabeculation noted suggesting some 
healing from standard treatment. The x-rays show some degree of healing after three months; therefore, the 
bone growth stimulator is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a non-spinal bone growth stimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated 
technique (78452). 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the enrollee is experiencing 
typical chest pains, with mixed hyperlipidemia. The Plan denied your request. The Plan says the requested test 
does not meet the requirements for approval. 
 
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 myocardial perfusion imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found at issue is the medical appropriateness and necessity of carrying out a 
radionuclide stress test prior to planned shoulder surgery. The enrollee has a history of chest pain. There is no 
documentation that the ECG shows an uninterpretable pattern, or that a treadmill stress test could not be carried 
out. There is no evidence provided that would support the need for radionuclide stress testing. In summary, 
there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in 
the enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (including 
attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique 
(78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64490, 64491). 
 
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are considered medically 
reasonable and necessary for the diagnosis and treatment of chronic pain in patients who meet all of the criteria. 
 
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 injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found the provided documentation does not indicate that the facet joints are identified as having pathology on imaging. The reviewer also found 
that several learned societies have found that sedation increases the risk of the procedure and decreases the 
accuracy of the result. Therefore, the reviewer found that the criteria have not been met and are 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64490, 64491).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an airway clearing vest for the enrollee. 
 
You asked the Plan to pre-approve the vest. You say that this si medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
 
 
 
 
 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 vest. Our reviewer says that the 
requested vest is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
COPD and recurrent pneumonia. There is no diagnosis for which Medicare covers this vest - cystic fibrosis, 
bronchiectasis, or neuromuscular disease. There is insufficient evidence that this treatment is beneficial for 
COPD. 
 
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 vest have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an airway clearing vest for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing the denial of authorization to a 
skilled nursing facility level of care. The Plan denied your request. The Plan says based on Medicare guidelines 
and the information we have about the enrollee's condition they do not meet all the requirements for approval. 
 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our 
reviewer also found the enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient 
basis in a skilled nursing facility (SNF) setting. The enrollee's care needs, custodial and intermittent, can, as a 
practical matter be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit on April 4, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be 
responsible to pay this because no medical services were rendered. The Plan denied your request. The Plan says 
the cost share has been applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35  
copayment for each in-person specialist visit.  
 
You have been asked to pay $35 for a specialist office visit. A specialist office visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category.  This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist office visit on April 4, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing (G0483) provided on April 13, 2022. 
 
You asked the Plan to pay for the drug testing (G0483). The Plan denied your request. The Plan says that the 
documentation does not support 22 or more drug classes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 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, 22 drug classes were tested. 
Based on this information, we decided that Medicare rules for coverage of the drug testing (G0483) have not 
been met. Therefore, we decided that the Plan has to pay for the drug testing (G0483) provided on April 13, 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 24, 2022. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
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 ambulance services provided on January 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service January 8, 
2021, to January 12, 2021. 
 
You asked the Plan to pay for procedure code S9500. You say that you would like this claim reprocessed based 
on the medical records. 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 S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service January 8, 2021, to January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this would be the best level of care for the enrollee. 
The Plan denied your request. The Plan says that the services the enrollee needs can be provided safely in other 
settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the members nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment 
by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation 
therapy program. There is not a reasonable expectation that this individual will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
The member can receive further services at a lower level of care. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy visits from February 1, 
2022, to February 24, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy visits. You say that you were not aware you 
would have to pay a copayment. The Plan denied your request. The Plan says the cost share was applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $60 per 
day for Medicare-covered radiation therapy visits.  
 
 
 
 
 
 You have been asked to pay $1020 for radiation therapy ($60/visit x 17 visits). Radiation therapy falls within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for radiation therapy visits from February 1, 2022, to February 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need skilled nursing services for physical 
therapy to get stable enough to climb steps prior to returning home. The Plan denied your request. The Plan 
says rules for SNF care have not been met. 
 
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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
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. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.