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

 
We decided that the Plan does not have to pay for the laboratory services (83520 and 87798) provided March 
30, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services 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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not 
otherwise specified. 
 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 laboratory services. Our reviewer found for code 83520, 
the documentation submitted was reviewed and does not meet criteria. The procedure code represents, "not 
otherwise specified". The medical record does not include specific procedure reported with this procedure code 
and therefore, cannot be verified. For code 87798, the documentation submitted was reviewed and does not 
meet criteria. The procedure code represents, "not otherwise specified". The medical record does not include 
specific procedure reported with this procedure code and therefore, cannot be verified. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (83520 and 87798) provided March 30, 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 need inpatient rehabilitation to get stronger so 
you can do the things you used to do. You say you feel you will benefit from rehabilitation. The Plan denied 
your request. The Plan says criteria for admission to the acute IRF setting have 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624). 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
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 genicular nerve radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found genicular nerve ablation is experimental for knee pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sixty-six (66) additional non-emergent routine 
transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need the additional 
trips for transportation. The Plan denied your request. The Plan says additional trips would exceed your benefit 
limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 84 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have used 
seventy-four (74) one-way transportation trips out of the allowed eighty-four (84) one-way trips approved. 
Once 84 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans 
rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sixty-six (66) additional non-emergent routine transportation trips (A0120).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 16, 2023, to 
February 1, 2023. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was submitted 
timely. The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim 
was correctly denied.  The Plan says that there is no evidence that it received the NOA prior to April 20, 2023. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 16, 2023. The NOA was not received by the Plan until April 20, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 16, 2023, to February 1, 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 AJ66 The Plan denied your request. The Plan says 
the enrollee can receive services safely in an alternate setting.  
 
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 enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement, however, the documentation 
doesnt support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation 
facility.  There is no indication that the enrollee would require skilled rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 22, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary.  The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 14, 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 is statutorily excluded due to the -GY modifier. 
 
The Plan must follow Medicare rules. The rules say that claims submitted using the GY modifier may be auto-
denied. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with the -GY modifier. 
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 14, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 16, 2023, billed with 
codes 99204, 74230, 72040, 70100, 70310, and 74240. 
 
You asked the Plan to pay for the services as billed. You say that these services were medically necessary.  The 
Plan denied your request. The Plan says this was not billed correctly.  
 
The Plan must follow Medicare rules. Medicare rules say that the POS code for mobile radiology service 
should be reported as the POS code at which the enrollee was seen. 
 
We looked at the file and Medicare rules. This was billed with an office POS code. The file shows that the 
services were provided at a nursing home. There is no evidence that the enrollee was seen at a doctor's office. 
Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on March 16, 
2023, billed with codes 99204, 74230, 72040, 70100, 70310, and 74240.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable narcotic infusion pump. 
 
You asked the Plan to pre-approve the narcotic infusion pump. You say that the enrollee has cancer and is in a 
lot of pain. The Plan denied your request. The Plan says the requested pump is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a preliminary trial of intraspinal opioid drug 
administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate adequately 
acceptable pain relief and degree of side effects (including effects on the activities of daily living) and patient 
acceptance.  
 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 narcotic infusion pump. Our 
reviewer says that the pump is not medically necessary. Our physician reviewer found that the provided records 
in this case do not show trial and success of the intraspinal opioid drug administration with a temporary 
intrathecal/epidural catheter, as required by the NCD.  
 
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 narcotic infusion pump have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable narcotic infusion pump.
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 LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for LTACH admission. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care soon. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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 the lab testing provided on September 5, 2022, billed with 5 
units of code 83520 and one unit of code 87798. 
 
You asked the Plan to pay for the testing as billed. You say that this testing should be paid as billed. The Plan 
denied your request. The Plan says these codes 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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. 
 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 testing as billed. Our reviewer says that the codes at issue 
are not supported.  Our reviewer found the provided records do not clarify that the services described by these 
two codes are included in the testing performed.  
 
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 testing as billed have not been met. Therefore, we decided that the Plan does 
not have to pay for the lab testing provided on September 5, 2022, billed with 5 units of code 83520 and one 
unit of code 87798.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you disagree with the denial and request 
reconsideration. The Plan denied your request. The Plan says you are requesting an additional 53 miles for a 
total of 103 miles and your benefit only allows 50 miles. The Plan also says you have exceeded your benefit 
limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 48 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ablation of malignant prostate tissue, transrectal, with 
high intensity-focused ultrasound (HIFU) (55880). 
 
You asked the Plan to pre-approve ablation of malignant prostate tissue, transrectal, with HIFU. You say that 
the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 ablation of malignant prostate tissue, 
transrectal, with HIFU. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found salvage ablation of malignant prostate 
tissue, transrectal, with high intensity-focused ultrasound (HIFU) is not medically reasonable and necessary in this case. The records do not show that a recent biopsy has been done to confirm recurrent cancer and the most 
recent prostate-specific antigen (PSA) was normal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ablation of malignant prostate tissue, transrectal, with HIFU have not been met. 
Therefore, we decided that the Plan does not have to pre-approve ablation of malignant prostate tissue, 
transrectal, with high intensity-focused ultrasound (HIFU) (55880).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 24, 2023, billed 
with codes 81226, 81240, 81241, 81306, 81328, & 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. 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 24, 2023, billed with codes 81226, 81240, 81241, 81306, 81328, & 81335.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection (64447) provided on January 19, 2023. 
 
You asked the Plan to pay for the injection. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 injection. Our reviewer says that the 
documentation does not support the codes billed. Our physician reviewer found the medical records submitted 
do not include sufficient documentation to validate the use of a 59 modifier to unbundle 64447 from code 
01402. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pay for an injection (64447) provided on January 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent testing (87491, 87798) billed for date of 
service December 17, 2022. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have reported the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 infectious-agent testing have been met. 
Specifically, medical records have not been provided to identify, nor to specify the results of, the testing at 
issue. Therefore, we decided that the Plan does not have to pay for infectious-agent testing (87491, 87798) 
billed for date of service December 17, 2022.