Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (EM) procedure provided on 
April 15, 2023, billed with code 99213-24. 
 
You asked the Plan to pay for the EM services as billed. You say that the modifier -24 was used to allow 
payment for this EM service. The Plan denied your request. The Plan says this was not billed correctly as it was 
performed on the same day as a minor procedure. 
 The Plan must follow Medicare rules. Medicare rules say that modifier "-25" is used to facilitate billing of 
evaluation and management services on the day of a procedure for which separate payment may be made.  
 
We looked at the file and Medicare rules. In this case, the EM code was billed with modifier -24 and was 
performed on the same date as a minor surgical procedure, 20610. This is not an appropriate use of this 
modifier. Such a modifier would be used to report an unrelated EM service in the days after a procedure. Based 
on this information, we decided that Medicare rules for coverage of the EM services as billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the evaluation and management (EM) 
procedure provided on April 15, 2023, billed with code 99213-24.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on November 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on December 15, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on November 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99231 billed for date of service February 13, 2023. 
 
You asked the Plan to pay for code 99231. You say that the patient was in the hospital and this service was for 
a follow-up for the patient's diarrhea. The Plan denied your request. The Plan says you billed this claim with an 
inappropriate pair of diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of K52.9 and R19.7. Code R19.7 is an Excludes1 code under 
code K52.9, so these two diagnoses cannot be billed together. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99231 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99231 billed for date of service February 13, 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 the enrollee meets IRF admission criteria. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T2046 billed for date of service December 2, 
2022 to December 31, 2022. 
 You asked the Plan to pay for procedure code T2046. You say that this claim should be processed under 
Medicaid instead of Medicare. 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 T2046 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T2046 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code T2046 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T2046 billed for date of service December 2, 2022 to December 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Custom Apollo Full Hereditary CGx genetic panel 
provided on August 7, 2022, and billed with codes 81162, 81201, 81272, 81292, 81295, 81298, 81307, 81317, 
81321, and 81351. 
 
You asked the Plan to pay for the genetic panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this test should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for the Custom Apollo Full Hereditary CGx genetic 
panel provided on August 7, 2022, and billed with codes 81162, 81201, 81272, 81292, 81295, 81298, 81307, 
81317, 81321, and 81351.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99214) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99214) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on October 25, 
2022. 
 
 
  
 
 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided was 
not medically necessary.  
 
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 this service. 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 the enrollee presented to the emergency department (ED) with anxiety during a dialysis 
session the same day. She was treated with Xanax which helped. Her vital signs were assessed and stable 
during evaluation except for high blood pressure. The workup was otherwise unremarkable for other causes of 
symptoms. The electrocardiogram did not show an ST-Segment Elevation Myocardial Infarction (STEMI). She 
was discharged against medical advice. Based on the low severity and low complexity of this case, it was not 
expected that the enrollee would require hospital services that would likely have 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) machine 
and supplies. 
 
You asked the Plan to pre-approve CPAP machine and supplies. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that CPAP is only covered for certain indications. 
 
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 CPAP machine and supplies. Our 
reviewer says that the requested device and supplies are not medically necessary. Our physician reviewer found 
the documentation indicates that there was nothing showing that the enrollee had significant obstructive sleep 
apnea that required treatment. There is no documented stoppage of breathing for more than 15 times per hour. 
There are no documented difficulties with thinking, or any behavioral health conditions. There is no 
documented inability to stay or fall asleep. There is no history of hypertension, CVA or cardiac disease. The 
review has determined that the enrollee does not have a diagnosis/condition that meets criteria for the requested 
CPAP. Therefore, the enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPAP machine and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuous positive airway pressure (CPAP) machine and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 30, 
2022, to September 2, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary and are supported in the medical record. The Plan denied your request. The Plan says the criteria for 
inpatient hospitalization were not met in this case, and the enrollee could have been treated in a lower level of 
care, such as observation. 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 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 the documentation provided supports that the necessary care could have been 
provided at lower level of service (e.g., observation). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 August 30, 2022, to September 2, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
December 9, 2022. 
 You asked the Plan to pay for procedure codes 87481 and 87653. The Plan denied your request. The Plan says 
payment for codes 87481 and 87653 is bundled into payment for code 87801. 
 
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 codes 
87481 and 87653 are column II codes to column I code 87801. 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 codes 87481 and 87653 billed for 
date of service December 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, and 87653, billed for 
date of service January 31, 2023. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87641, and 87653. The Plan denied your request. 
The Plan says payment for codes 87150, 87481, 87641, and 87653, is bundled. 
 
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 87150 
is a column II code to column I code 87500. We have also confirmed that codes 87481, 87641, and 87653, are 
column II codes to column I code 87150. 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 codes 87150, 87481, 87641, and 87653, billed for date of service 
January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR panel testing coded as 87641-59, 87653, 
87640-59, 87481 x5, and 87798 x1 provided March 3, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please review the medical documentation to 
support the diagnosis coding and medical necessity of the denied line items. The Plan denied your request. The 
Plan says The PCR testing is considered unproven and 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. The standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the urine PCR panel testing coded as 87641-59, 87653, 87640-59, 87481 x5, and 87798 x1 provided March 
3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided on March 08, 2023, to 
March 11, 2023. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that you were told by your primary care 
provider to go to the emergency room. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
stay provided on March 08, 2023, to March 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from 
February 4, 2022, to February 14, 2022.  
 You asked the Plan to pay for the services. You say that this should be paid for.  The Plan denied your request. 
The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our physician reviewer found 
the documentation does not support the correct PDPM was submitted by the skilled nursing facility. The 
documentation available for review that pertains to the appropriate look-back period does not support that the 
member required or received parental/intravenous (IV) feeding while not a resident within six (6) days of the 
assessment. The third alphanumeric character in the PDPM were not correct. The partial adjustment to PDPM 
KFPD1 was appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services rendered from February 4, 2022, to February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 18, 2022, billed with 
codes 81225, 81328, 81335, 81479, 81238, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are requesting a redetermination of 
the denial and have enclosed documentation to substantiate the claim. The Plan denied your request. The Plan 
says panel testing should be billed using one CPT code on the claim. The clinical value and effectiveness of 
Genetic Cardiac Testing have not been demonstrated in the peer-reviewed 
literature. 
 
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. The clinical value and effectiveness of Genetic Cardiac Testing in the setting of high blood 
pressure (hypertension), type 2 diabetes, high cholesterol, coronary heart disease, stroke and sleep apnea have 
not been demonstrated in the peer-reviewed literature. 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 October 18, 2022, billed with codes 81225, 81328, 81335, 
81479, 81238, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve 
branches including imaging guidance, when performed (64624).  
 
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging 
guidance, when performed. You say that the enrollee is in severe pain. The Plan denied your request. The Plan 
says a review of the current medical literature does not consider this service to be standard medical treatment 
for the enrollee's condition.  
 
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 destruction by neurolytic agent, 
genicular nerve branches including imaging guidance, when performed. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. The review has determined that the requested genicular nerve radiofrequency ablation of 
the left knee is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent, genicular nerve branches including imaging 
guidance, when performed have not been met. Therefore, we decided that the Plan does not have to pre-
approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when 
performed (64624).