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

 
We decided that the Plan has to pay for Guardant360 testing (0334U) billed for date of service March 17, 2023. 
 
You asked the Plan to pay for Guardant360 testing. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says that this claim was submitted with an incorrect 
date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. However, there are exceptions to this rule. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 testing have been met. Specifically, the specimen in this case was a tissue sample 
which would have been collected during a medically necessary and appropriate hospital stay, and the test itself 
was performed after discharge. It is also likely the sample was stored for some time. Based on the 
documentation provided, one of the exceptions has been met, which means that the appropriate date to report in 
this case would be the date the test was performed. In this case, the correct date is March 17, 2023. Therefore, 
we decided that the Plan has to pay for Guardant360 testing (0334U) billed for date of service March 17, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93228, 93229, R0070, and Q0092 rendered 
on February 22, 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 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 93228: 
 
External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG 
triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; 
review and interpretation with report by a physician or other qualified health care professional 
 
CPT 93229: 
 
External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real 
time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG 
triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; 
technical support for connection and patient instructions for use, attended surveillance, analysis and 
transmission of daily and emergent data reports as prescribed by a physician or other qualified health care 
professional 
 
Healthcare Common Procedure Coding System (HCPCS) R0070: 
 
Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or 
location, one patient seen 
 
HCPCS Q0092: 
 
Set-up portable x-ray equipment 
 
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 terms of CPT 93228 and 
93229, the procedure report does not include any documentation of the interpretation and report. The report 
does include a "conclusion;" however, the verification cannot be made for a technician or qualified healthcare 
professional qualified note. There is no documentation of connection and patient instruction. 
 
In terms of Q0092 and R0070, these codes cannot be verified, as there is no radiology service reported for the 
dates of service billed. 
 
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 codes 93228, 93229, R0070, and Q0092 rendered on February 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
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 the enrollee is not noted to meet 
diagnostic criteria for both AD and FTD. In as much the enrollee has not met the initial criteria for coverage of 
this service. Therefore, medical necessity cannot be established at this time. 
 
 
 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 a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units each of procedure code 92540 and 92546 rendered 
on April 4, 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 the provider has not documented any medically necessary reason for performing extra units.  
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 the denied codes is: 
 
CPT 92540: 
 
Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with 
recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, 
bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording 
 
CPT 92546: 
 
Sinusoidal vertical axis rotational testing 
 
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 documentation supports that 
the additional units in question were performed but does not document why these additional units were 
medically necessary. 
 
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 two units each of procedure code 92540 and 92546 rendered on April 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on May 9, 2023. 
 
You asked the Plan to pay for drug testing. You say that this service was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says there is insufficient documentation to support the 
service provided was medically necessary and requested by the enrollee's physician. 
 
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 drug testing have been met. 
Specifically, the physician order for these services indicates only that a "Urine MCT (All-in-One)" test is 
requested. There is no documentation to clarify what is included and what drugs are specifically requested for 
testing in this panel. Without additional information, we cannot verify that the service provided was explicitly 
requested by the enrollee's treating physician and was medically necessary. Therefore, we decided that the Plan 
does not have to pay for definitive drug testing (G0483) provided on May 9, 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 appealing the denial for the admission to an 
IRF. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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 found that the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided on 
February 20, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that this service was medically 
necessary. The Plan denied your request. The Plan says diagnosis code, K82.A2, has a "code first" note and the 
underlying condition should be sequenced first. 
 
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 an 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 emergency department visit reviewer says that the billed 
service is not supported. Our reviewer found that although the medical record includes an evaluation and 
management service provided, diagnosis code, was incorrectly reported. Per the International Classification of 
Diseases (ICD)-10 guidelines for K82.A2, instruction is given. "Code First the type of cholecystitis. In this 
case, another diagnosis code would be reported in addition to the code reported. The Centers for Medicare and 
Medicaid Services (CMS) require all Medicare practitioners to use ICD-10 diagnosis codes with the highest 
specificity. A query should be made to the treating provider prior to billing.  
 
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 emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for the emergency department visit (99285) provided on February 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services reported with DRG 189 rendered 
from November 7, 2022, to November 9, 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 diagnosis of acute respiratory failure with 
hypoxia is not supported. 
 
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 DRG 189. 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 enrollee presented with shortness of breath, in the setting of known chronic obstructive pulmonary 
disease (COPD) and ongoing smoking. While the enrollee was hypoxic, she responded well to oxygen and did 
not require ventilatory support. The documentation does not support a diagnosis of respiratory failure. As such, 
the billing of J96.01 is not supported.  
 
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 reported with DRG 189 rendered from November 7, 2022, to November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulator (64555). 
 
You asked the Plan to pre-approve a peripheral nerve stimulator. You say that you are requesting a fast appeal 
due to the severity of the enrollee's pain and the failure of other treatments to help them. The Plan denied your 
request. The Plan says the requested device is not reasonable and 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 pre-approve a peripheral nerve stimulator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the use of peripheral nerve stimulation for the treatment of low back pain 
from spinal stenosis is experimental/investigational at this time and is the subject of ongoing clinical trials. 
Therefore, the request is deemed not medically reasonable and 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 a peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a peripheral nerve stimulator (64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 22, 2023.  
 
You asked the Plan to pay for the medical services. You say that the diagnosis code is supported and can be 
used as primary. The Plan denied your request. The Plan says the primary diagnosis is not appropriate.  
 The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with a Code first note should not 
be used as primary diagnoses. 
 
We looked at the file and Medicare rules. The claim was billed with primary diagnosis code F06.34. This code 
has a Code first note stating to sequence the underlying physiological condition first. Based on this 
information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, 
we decided that the Plan does not have to pay for the medical services provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services provided on April 1, 2023.  
 
You asked the Plan to pay for the debridement services. You say that the services should be paid.  The Plan 
denied your request. The Plan says the records submitted do not include a signature from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the debridement services have not been met. Specifically, the documentation submitted does not include a valid signature from the persons responsible for the care of the beneficiary. Therefore, we decided 
that the Plan does not have to pay for the debridement services provided on April 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code 87506. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says this code does not accurately reflect the 
services provided, which would be better described with another procedure code. 
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, 
Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, 
multiple types or subtypes, 6-11 targets. 
 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 87506. Our reviewer says that this code is 
not supported. Our reviewer found the laboratory report does not include documentation of 6-11 targets. In this 
case there is a more comprehensive code to report for the number of targets tested. 
 
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 87506 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87506 billed for date of service October 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services rendered from October 27, 2022, 
to November 2, 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 DRG 872. 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 enrollee, a diabetic, presented with fever in the setting of an ongoing right foot/heel infection. The 
enrollee was found to have osteomyelitis and an abscess, which was drained. There is no evidence that the 
enrollee had sepsis (hypotension, hypoperfusion, organ failure). As such, the billing of A41.9 is not supported.  
 
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 October 27, 2022, to November 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 11, 2021, to 
August 9, 2021.  
 
You asked the Plan to pay for the home health services. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says the provider failed to submit orders for 
all the billed visits on the claim. 
 
The Plan follows Medicare rules. Medicare rules say that orders on the plan of care must indicate the type of 
services to be provided to the patient, both with respect to the professional who will provide them and the 
nature of the individual 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 the home health services. Our reviewer says 
that the billed services are not supported. Our physician reviewer found that the documentation does not 
support that the correct patient driven payment model (PDPM) health insurance prospective payment system 
(HIPPS) code was submitted by the organization. The documentation does not indicate there was appropriate 
physician orders for the services rendered. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from July 11, 2021, to August 9, 2021.