Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from November 
14, 2022, to November 17, 2022. 
 You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient admission was 
medically necessary. The Plan denied your request. The Plan says the enrollee was medically stable and could 
have been transferred to an in-network hospital. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that at the time of admission, the enrollee was stable and was not expected 
to require hospital care that would have likely crossed two midnights.  
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from November 14, 2022, to 
November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 11, 2023, billed with 
codes 81432 and 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that the test was ordered due to its clinical 
validity. 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 NGS panel was not billed with a single code as required. The 
records do not show that the enrollee has a cancer diagnosis. This testing is not covered as a screening service. 
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 April 11, 
2023, billed with codes 81432 and 81433.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 7, 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 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 these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on May 9, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the billed services are nor supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Based on this information, we decided that 
Medicare rules for coverage have not been met. 
 
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 96521 is refilling and maintenance 
of portable pump. We find that CPT code 96521 is not supported in the medical record. The records do not 
document that this service was provided. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for Outpatient 
Intravenous Insulin Therapy (OIVIT) services provided on May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 6, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column II code to column I code 81455 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gradient compression stocking, below knee (A6530). 
 
You asked the Plan to pre-approve a gradient compression stocking. You say that you have been trying to get a 
compression sock for over two months. You also say that you have tried ordering ones from a catalog, but they 
do not fit properly and are uncomfortable. The Plan denied your request. The Plan says the requested service is 
not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that gradient compression stockings (such as code 
A6530) are an example of a wound care item which is non-covered under the surgical dressing benefit. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a gradient compression stocking have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a gradient compression stocking, below knee (A6530).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service March 22, 2023. 
 
You asked the Plan to pay for the billed services. You say that pathology reports were provided. The Plan 
denied your request. The Plan says the testing is excessive. 
 
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 looked at the file and the rules. We find that the urinary tract infection testing is not supported. The records 
do not show that this test was ordered to treat a specific medical problem. The records do not show how the 
testing will impact clinical management. The panel testing was not billed with a single code as required. 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 the panel testing billed for date of service March 
22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E2311, E2313, E2377, E1007, E2361, 
E1028, E2620, E0955, E1028, E2622, E1012, K0040, E0953, E1028, K0108, and K0108). 
 
You asked the Plan to pre-approve a Group 3 standard power wheelchair and additional items and accessories. 
You say that you would like the clinicals to be reviewed again. The Plan denied your request. The Plan says the 
enrollee does not have a medical need for multiple power options included with K0861 group 3 power 
wheelchair. The Plan also says the electronic connection, harness, and expandable controller cannot be covered 
as it is not medically necessary to control the three requested power options through the joystick (drive 
interface). 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options (such as 
code K0861) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules 
also say that if the PWC base is not covered, then related accessories will be denied. 
 
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 3 standard 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 provided records from the face-to-face wheelchair evaluation 
performed by the prescribing provider do not support that the enrollee is high risk for skin breakdown, has a 
history of pressure ulcer(s) or has had skin flap surgery. Records do not document that the enrollee performs 
bladder self-catheterization or that they have increased muscle tone or spasticity to meet criteria for the power 
tilt and/or recline and thus the multiple power option wheelchair base. Our reviewer also found that as the 
requested wheelchair base does not meet Medicare coverage criteria, the requested accessories are not covered.  
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 3 standard 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 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E2311, E2313, 
E2377, E1007, E2361, E1028, E2620, E0955, E1028, E2622, E1012, K0040, E0953, E1028, K0108, and 
K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as they do not meet the clinical 
requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our physician reviewer 
found that the record indicates you are not being treated with insulin or have a history of problematic 
hypoglycemia. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 13, 2023. 
 
You asked the Plan to pay for the services. 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 M54.50 has an Excludes1 note in relation to S39.012D. This means that 
the two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for 
the services provided on April 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency care (99285) provided on March 25, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the code was billed 
with an inappropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier 59 should not be appended to an 
evaluation and management (E/M) service. 
 
We looked at the file and Medicare rules. In this case, it is inappropriate to bill E/M code 99285 with modifier 
59. 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 emergency care (99285) provided on March 
25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 9, 2023, billed with 
procedure code 93010. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. 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 N20.1 has an Excludes1 note in relation to N13.2. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the practitioner services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on May 9, 2023, billed with procedure code 93010.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve endovascular revascularization (37229, 37225). 
 
You asked the Plan to pre-approve endovascular revascularization. You say that the services are necessary. The 
Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 endovascular revascularization. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the documentation supports the medical necessity of the procedure in 
question. The enrollee has documented short distance disabling claudication and associated documentation of 
abnormal pulse exam, abnormal ankle-brachial indexes (ABIs), and focal occlusion in the left superficial 
femoral artery. The enrollee is status post revascularization on the right and has noted improvement since then 
on that side but is now limited by her left leg. It should be noted, that without treatment on the left, the enrollee 
will not be able to experience any improvement from the procedure she had of the right.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovascular revascularization have been met. Therefore, we decided that the 
Plan has to pre-approve endovascular revascularization (37229, 37225).  
 
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 the Cxbladder test (0012M) provided on February 7, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 2, 2023, billed with code 
81403. 
 
You asked the Plan to pay for the genetic testing. You say that your physician who ordered the test, feels that 
the test was clinically indicated based on your symptoms, signs, laboratory results and the way the test would 
be use in your future treatment and care. The Plan denied your request. The Plan says this testing 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 looked at the file, and Medicare rules. This test is listed as a Tier 2 genetic testing that is unlikely to impact 
therapeutic decision making, directly impact treatment, outcome and/or clinical management in the care of the 
beneficiary and will be denied as not medically necessary. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on June 2, 2023, billed with code 81403.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for paramedic intercept services (A0432) provided on May 14, 2023. 
 
You asked the Plan to pay for paramedic intercept. You say that these services were medically necessary and 
have been paid before when pickup occurred in the same ZIP Code. The Plan denied your request. The Plan 
says that this service cannot be paid as it was not billed with a necessary mileage code. 
 
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. Specifically, the Plan has stated that this claim cannot be processed as it is 
missing a vital piece of information: a mileage procedure code. However, the rules do not state that this code is 
explicitly necessary, only that mileage is reported separate from the main ambulance service. If no mileage is 
provided, it would not be appropriate to report mileage. In addition, another procedure code would not be 
considered a required piece of information to process a claim. The Plan has provided no other reason for denial in this case and has not properly substantiated the denial presented. Therefore, we decided that the Plan has to 
pay for paramedic intercept services (A0432) provided on May 14, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service April 25, 
2023.  
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. 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 99285 is 1. The MAI value for this code is 3. You billed 1 unit of this code 
under this claim and 1 unit of this code under another claim that was previously processed and paid by the plan, 
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 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 billed for date of service April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
April 5, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service April 5, 2023.