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

 
We decided that the Plan does not have to pay for the laboratory test (81479) provided on March 9, 2023. 
 
You asked the Plan to pay for the laboratory test. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says the claim for this molecular pathology testing did 
not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (81479) 
provided on March 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 4, 2023, billed with 
codes 81225, 81226, 81240, 81241 and 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test 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 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 
February 4, 2023, billed with codes 81225, 81226, 81240, 81241 and 81328.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36556 billed for date of service April 11, 
2023. 
 
You asked the Plan to pay for procedure code 36556. You say that this code is supported in the medical record. 
The Plan denied your request. The Plan says this code 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 36556 is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older. 
 
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 procedure code 36556. Our reviewer says that code 36556 is 
not supported. Our reviewer found there is a more appropriate procedure code for the service described in the provider note. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 36556 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 36556 billed for date of service April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 billed for date of 
service April 6, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for issues with diabetes. 
The Plan denied your request. The Plan says the medical records do not support the codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 96365, 96366, and 96521 are not supported in the medical record. The file shows what 
outpatient intravenous insulin therapy was billed using codes 96365 and 96366. There is a more accurate code 
that describes the services provided. The records do not document the refilling and maintenance of a pump, 
billed with code 96521. Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, and 96521 
billed for date of service April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator and portable oxygen rendered on 
March 9, 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 the billed diagnosis codes are not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with diagnosis codes that 
exclude each other. 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 pay for the oxygen concentrator and 
portable oxygen rendered on March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy-duty power wheelchair (K0843) and 
additional items and accessories (codes E2361, E2311, E2313, E2377, E1007, E1028, E2331, E0955, E1012, 
K0040, and E2602). 
 
You asked the Plan to pre-approve a group 2 heavy-duty power wheelchair and additional items and 
accessories. You say that the requested power wheelchair and its required accessories is the appropriate 
equipment the enrollee will need for safety and independence to help them complete MRADLs. The Plan 
denied your request. The Plan says this request cannot be approved. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 Multiple Power Option PWC (such as code 
K0843) is covered if all of the basic coverage criteria for a PWC are met and if the criteria listed in the 
Medicare rules section of this letter 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 a group 2 heavy-duty power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. The enrollee is blind 
and there is no evidence provided that they may safely manage a power wheelchair. Our reviewer found that 
none of the evaluations address safety with the enrollee's blindness. Our physician reviewer also found that the 
enrollee has sufficient strength and function in their upper extremities to manage standard power drives. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 2 heavy-duty power wheelchair and additional items and accessories 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy-duty 
power wheelchair (K0843) and additional items and accessories (codes E2361, E2311, E2313, E2377, E1007, 
E1028, E2331, E0955, E1012, K0040, and E2602).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99253 billed for date of service January 31, 
2023. 
 
You asked the Plan to pay for procedure code 99253. You say that you disagree with the Plan's denial. 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 99253 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99253 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99253 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99253 billed for date of service January 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 for date of service December 6, 2022. 
 
You asked the Plan to pay for procedure code 76942. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 76942 is ultrasonic guidance for needle placement (eg, 
biopsy, aspiration, injection, localization device), imaging supervision and interpretation. 
 
We find that CPT code 76942 is not supported in the medical record. Specifically, the medical records do not 
include documentation of permanently recorded images. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76942 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76942 for date of service December 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs physical therapy but 
won't be accepted into inpatient rehabilitation because they are not cooperating due to pain and developing an 
ulcer. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services 
requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no specific therapies or treatments that the enrollee would receive at the 
LTACH that they are not receiving at the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on April 5, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and was reported 
appropriately. 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 (G0483) provided on April 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge management services (99239) provided on 
February 26, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99239 is "Hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter". 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that 
more than 30 minutes of hospital discharge day management services were provided on the date of service in 
question. 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 discharge management services (99239) 
provided on February 26, 2023.
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. 
 
You asked the Plan to pre-approve IRF care. You say that you are used to doing things for yourself and 
wanting to go to therapy to be able get back to your normal level of functioning. The Plan denied your request. 
The Plan says you do not meet the requirements for approval. The Plan says that the services needed may be 
provided safely in a lower level of care. 
 
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. Our 
physician reviewer agrees with the Plans denial of IRF placement and suggestion that you first seek acute 
hospital 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on April 18, 
2023. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed services were 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 99233 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded. 
 
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 subsequent hospital care. Our reviewer says that CPT 
code 99233 is not supported. Our reviewer found the documentation shows moderate medical decision making. 
The complexity is an undiagnosed new problem (moderate), data/complexity was high, and the risk was 
moderate. Our reviewer also found that the records do not support a high level of medical 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 subsequent hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the subsequent hospital care (99233) provided on April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88177 billed for date of service May 9, 2023.  You asked the Plan to pay for procedure code 88177. You say that these services are supported in the medical 
record. 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 88177 is 6. The MAI value for this code is 3. You billed 7 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 88177 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88177 billed for date of service May 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee does require an LTACH 
level of care and is stable for discharge to that level of care. The Plan denied your request. The Plan says 
criteria for admission to the LTACH have not been met.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently receiving care at an acute care facility. There are no specific 
therapies or treatments that the enrollee would receive at the LTACH that they are not receiving at the acute 
care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99348 billed for date of service April 13, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the 
treatment was rendered in an invalid place of service. 
 
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 99348 is home or residence visit for the evaluation and 
management of an established patient. We find that CPT code 99348 was billed with a place of service code 33, 
indicating a custodial care facility, not a skilled nursing or nursing facility. Based on this information, we 
decided that Medicare rules for coverage of the billed services have been met. Therefore, we decided that the 
Plan has to pay for procedure code 99348 billed for date of service April 13, 2023.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service April 6, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that this service was medically necessary for the 
patient's health. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service December 
13, 2022.  
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99232 is bundled into payment for code 99238. 
 
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 99232 is a column II code to column I code 99238 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99232 billed for date of service December 13, 2022.