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

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 22, 2023. 
 
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 two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that I25.10 has an Excludes1 note in relation to I20.0. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health skilled nursing visits (G0299 x10). 
 You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not 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 pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found there is no 
change in condition. Skilled nursing services were completed and continued services were not necessary for the 
enrollee's stable chronic condition. 
 
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 pre-approve the home health skilled nursing visits (G0299 x10).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service June 18, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 99284 is bundled into payment for code 99285. 
 
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 99284 
is a column II code to column I code 99285. 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 99284 billed for date of service June 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lamotrigine billed with code 80175 for date of service March 
4, 2023. 
 
You asked the Plan to pay for lamotrigine. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the service billed is 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 80175 is Lamotrigine. 
 
We find that CPT code 80175 is not supported in the medical record. Specifically, the submitted medical 
records include laboratory results that indicate the billed services were performed by a health care provider 
other than the billing health care provider. The billed services cannot be verified. Based on this information, we decided that Medicare rules for coverage of lamotrigine have not been met. Therefore, we decided that the Plan 
does not have to pay for lamotrigine billed with code 80175 for date of service March 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 15, 2022, billed 
with codes 81162-90, 81201-90, 81218-90, 81292-90, 81295-90, 81298-90, 81307-90, 81317-90, 81321-90, 
81351-90, 81209-90, 81314-90, 81334-90, 81345-90, 81272-90, 81479-90. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 15, 2022, billed with codes 81162-90, 81201-90, 81218-90, 81292-90, 81295-90, 81298-90, 81307-
90, 81317-90, 81321-90, 81351-90, 81209-90, 81314-90, 81334-90, 81345-90, 81272-90, 81479-90.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions using solution 
injection (62264). 
 
You asked the Plan to pre-approve percutaneous lysis of epidural adhesions using solution injection. You say 
that you are requesting reconsideration and have submitted medical records to support appeal. The Plan denied 
your request. The Plan says a review of the current medical literature does not support this service to be 
reasonable and 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 pre-approve percutaneous lysis of epidural 
adhesions using solution injection. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found percutaneous lysis of epidural 
adhesions refers to the disruption of fibrous tissue in the epidural space of the spine. This procedure is also 
known as the RACZ procedure or epidural neurolysis. This modality for chronic pain management is still being 
studied to see if this treatment is as good or better than standard treatment for chronic pain. Thus far, there is 
insufficient medical literature to support the overall use of this procedure. More research is needed to show 
safety and efficacy of the procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous lysis of epidural adhesions using solution injection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions 
using solution injection (62264).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99282 billed for date of service June 15, 
2023. 
 You asked the Plan to pay for procedure code 99282. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 99282 is bundled into payment for 
code 99283. 
 
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 99282 
is a column II code to column I code 99283. 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 99282 billed for date of service June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service June 27, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that this code is payable. 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 88341 is 13. The MAI value for this code is 3. You billed 19 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service June 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve total electric hospital bed. You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says a total electric hospital bed is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that total electric hospital beds are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a total electric hospital bed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95718 rendered from June 26, 2023, to June 
28, 2023. 
 
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 95718 (1 unit) 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 95718 is "Electroencephalogram (EEG), continuous 
recording, physician or other qualified health care professional review of recorded events, analysis of spike and 
seizure detection, interpretation and report, 2-12 hours of EEG recording; with video (VEEG)." 
 
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 procedure report does not 
include sufficient documentation to verify procedure billed. Although the medical record documents VEEG, 
the report describes EEG procedure. This procedure cannot be verified in documentation submitted. 
 
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 procedure code 95718 rendered from June 26, 2023, to June 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 11, 2023, billed with 
codes 87798 and 87481. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was a laboratory panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the laboratory panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 11, 2023, billed with codes 87798 and 87481.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoProTM Motion G device (L8702). 
 
You asked the Plan to pre-approve the MyoProTM device. You say that the device is medically necessary. The 
Plan denied your request. The Plan says the MyoProTM is unproven and not medically necessary due to 
insufficient evidence of safety and/or efficacy. 
 
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 MyoProTM device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that current clinical guidelines for adult stroke rehabilitation and recovery designate 
robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise 
therapies" with unproven benefit in the home environment. Although records from the device 
manufacturer/vendor argue medical necessity of the requested device, records from the enrollees actual 
treating provider do not clarify why the requested device is the most appropriate treatment for the enrollees 
condition. The only reference to treatment of the enrollees hemiparesis in the provided medical records is, 
continue supportive care. Mobility via wheelchair. In addition, provided records report night muscle spasms 
treated with baclofen which may be a contraindication to use of the device.  
 
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 MyoProTM device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MyoProTM Motion G device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic and retainer crown (D6750, D6240) provided on 
May 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a pontic 
and retainer crown (D6750, D6240) provided on May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (85652 and 85025) billed for date of 
service December 14, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says there is insufficient documentation to 
support these services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, the records provided do not include any documentation of the collection date of the specimen 
tested in this case. Without this information, we cannot verify whether these services were reported with the 
correct date of service. Therefore, we decided that the Plan does not have to pay for laboratory services (85652 
and 85025) billed for date of service December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99202) for a driver's license evaluation. 
 
You asked the Plan to pre-approve an office visit. You say that the enrollee needs a driving evaluation in order 
to reinstate his driving privileges. The Plan denied your request. The Plan says there is no reasonable 
expectation that the enrollee has recovered and could drive safely and an evaluation to confirm a disability is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that an assessment for the sole purpose of 
disqualifying a patient from driving is not a covered benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an office visit have not been met. Specifically, the need for the assessment must be related to the 
presence of, or recovery from, a specific injury or illness. An assessment for the sole purpose of disqualifying 
an enrollee from driving is not a covered benefit. Therefore, we decided that the Plan does not have to pre-
approve an office visit (99202) for a driver's license evaluation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0482) provided on May 31, 2023. 
 
You asked the Plan to pay for drug testing. You say that this service was necessary and is payable by Medicare. 
The Plan denied your request. The Plan says the code used to report the service provided is not supported in the 
medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), 
including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records provided 
support that drugs from only two drug classes were definitively tested in this case. There is another procedure 
code which would describe the services reflected in the records 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 (G0482) provided on May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 10, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 10, 2023.