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

 
We decided that the Plan does not have to pay for FoundationOne Liquid Biopsy (0239U) provided November 
5, 2022 
 
You asked the Plan to pay for the laboratory service. You say that FoundationOne Liquid CDx is a medically 
necessary laboratory test for patients with advanced stage, solid tumor cancers who have decided to seek 
further treatment. The Plan denied your request. The Plan says under Medicare, the request is not medically 
necessary. 
 
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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found this enrollee had a stage IIA colon cancer diagnosed in May 2022 treated with 
resection. FoundationOne Liquid CDx was sent on October 26, 2022. There are no records that mention 
recurrence of disease. Although microsatellite instability (MSI)/mismatch repair (MMR) testing is 
recommended, tissue is preferred which is available. The service was 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for FoundationOne Liquid Biopsy (0239U) provided November 5, 2022
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on December 4, 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 Current Procedural Terminology (CPT) code 99285 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
does not support the CPT code 99285. The documentation available for review does not support that the 
presenting problems were of high severity or that the medical decision was of high complexity. 
 
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 emergency department services (procedure code 99285) rendered on December 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a venous angioplasty and stent placement (37238, 
37248) to be provided by an out-of-network (OON) facility. 
 
You asked the Plan to pre-approve a venous angioplasty and stent placement. You say that you disagree with 
the denial and have submitted medical records for review. You also say this is the only facility where the 
provider performs procedures. The Plan denied your request. The Plan says the requested service is not covered 
because the procedure will be performed in an OON facility. The enrollee must use network providers and 
facilities for medical 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a venous angioplasty and stent placement (37238, 37248) to be provided by an out-of-network (OON) facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99360, A4215) provided on September 26, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is 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. Medicare rules also 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. 
 
We find that payment for CPT code 99360 is not supported in the medical record. Specifically, this code is not 
payable under the Physician Fee Schedule or the Outpatient Prospective Payment System (OPPS). Based on 
this information, we decided that Medicare rules for coverage of the services have not been met. 
 
In this case, the MUE for CPT code A4215 is 0. The MAI value for this code is 3. You billed 15 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 A4215 have not been met. Therefore, we decided that the 
Plan does not have to pay for the services (99360, A4215) provided on September 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from December 17, 
2021, to January 5, 2022. 
 
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. 
 
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 diagnosis code I50.21. 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 the documentation does not indicate that the treatment ordered by the treating medical 
providers supported a diagnosis code of I50.21 (Acute systolic (congestive) heart failure). In this case, the 
documentation does not consistently and completely support the assigned secondary diagnosis code. The 
decision to remove the secondary diagnosis code and adjust the DRG is upheld.  
 
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 rendered from December 17, 2021, to January 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan of the brain; 
metabolic evaluation. 
 
You asked the Plan to pre-approve the PET scan. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no indication that the exam is being requested in the context of a clinical 
trial. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that the records do not demonstrate that 
the enrollee has met diagnostic criteria for either Alzheimer's dementia or fronto-temporal dementia - let alone 
both diagnoses. This request does not meet the criteria for coverage. 
 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 PET scan have not been met.  Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) scan of the brain; metabolic evaluation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-covered ambulance mileage (A0888) rendered on 
September 30, 2022. 
 
You asked the Plan to pay for the services. You say that ambulance transport was not medically necessary, 
because the enrollee did not have the strength to walk or stand up easily. The Plan denied your request. The 
Plan says the enrollee did not meet criteria. 
 
Medicare pays for ambulance services only with mileage to the nearest appropriate facility equipped to treat the 
patient. 
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found that 
although the transportation was medically necessary, the enrollee was transported to a more distant facility at 
the request of her husband. The documentation does not show that transport to this more distant facility was 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for non-covered ambulance mileage (A0888) rendered on September 30, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing provided on November 1, 2022. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says that this claim is 
redundant as this testing was already performed on this date of service. 
 
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. The Plan argues that this claim is redundant as this testing was already 
performed on this date of service. However, the Plan has not provided documentation of another claim billed 
for the services at issue in this case. The records only support that the drug testing at issue was performed on 
this date, and no other testing was performed. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the drug testing provided on November 1, 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99213) rendered on January 
17, 2023. 
 
You asked the Plan to pay for the services. You say that medical records were sent in. The Plan denied your 
request. The Plan says a modifier was not billed on the claim to represent the services as unrelated from the 
post-operative period of a global procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 99213 is not supported in the medical record. Specifically, this was billed within the 
global period for CPT 23500 and does not have a modifier reported to distinguish it as unrelated to that procedure. 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 an office visit (procedure code 99213) 
rendered on January 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on May 24, 2022 to June 
23, 2022.  
 You asked the Plan to pay for home health services. You say that  The Plan denied your request. The Plan says 
the submitted medical records provide proof that the services rendered were medically necessary. 
 
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 pay for home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found that the enrollee had a 
wound. The nature of the wound is not identified. The provided wound care was not complex. The enrollee's 
homebound status is not illustrated. The inability of the patient or spouse to provided wound care is not 
illustrated. As such, the provided wound care is not shown to have been medically necessary or reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided on May 24, 2022 to June 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) of the heart with 
calcium scoring (75571). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says this test is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our physician reviewer 
found the chart notes provide a diagnosis of family history of coronary artery disease and mentions that both of 
your parents died from cardiac issues. The review has determined that the requested CT scan is 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the computed tomography (CT) of the heart with calcium scoring (75571).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. 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 follows Medicare rules. Medicare rules say that cardiac event monitors are 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is insufficient documentation 
to support the medical necessity for insertion of an ICM in this 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 insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305, 88341, and 88342 billed for date of 
service July 21, 2022. 
 You asked the Plan to pay for procedure code(s) 88305, 88341, and 88342. You say that full payment should 
be made for these services. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305, 88341, and 
88342. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88305, 
88341, and 88342. Based on this information, we decided that Medicare rules for coverage of procedure code 
88305, 88341, and 88342 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88305, 88341, and 88342 billed for date of service July 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 21, 2022, billed 
with code 69209. 
 
You asked the Plan to pay for the services as billed. You say that this should be paid as billed.  The Plan denied 
your request. The Plan says code 69209 is not payable in the hospital setting.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code 69209 has a Professional Component/Technical Component (PC/TC) indicator of 5. This indicator 
identifies codes that describe services covered incident to a physician's service when they are provided by 
auxiliary personnel employed by the physician and working under his or her direct personal supervision. 
Payment may not be made by carriers for these services when they are provided to hospital inpatients or 
patients in a hospital outpatient department. This service was provided in an off-campus outpatient hospital department. Based on this information, we decided that Medicare rules for coverage of the services as billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided 
on October 21, 2022, billed with code 69209.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L5 kyphoplasty. 
 
You asked the Plan to pre-approve L5 kyphoplasty. 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 follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific 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 L5 kyphoplasty. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found detailed documentation regarding the 
current L5 compression fracture being acute and/or subacute is not evident. The documentation does not 
support that she is hospitalized. There is no indication of moderate-severe pain or that the pain is worsening 
with a progression of vertebral height loss, greater than 25% vertebral body height reduction, kyphotic 
deformity on diagnostic imaging studies at L5, or a severe impact on daily functioning. Therefore, the enrollee 
does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L5 kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (procedure code 99220) rendered on 
April 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 the records do not support the services 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. 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the history did not include a 
review of systems. The physical examination was not detailed or comprehensive. There was no complex 
decision-making.  
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 initial observation care (procedure code 99220) rendered on April 29, 2022.