Persius/hicric huggingface dataset:
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 
May 16, 2022.  
 
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 May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that a note during the enrollee's hospitalization indicates suspected COPD, but outpatient records do not include 
COPD as a diagnosis. There are no pulmonary function tests. There is no diagnosis of thoracic restrictive 
disease or neuromuscular disease. There is no arterial blood gas (ABG) done while stable to document chronic 
carbon dioxide (CO2) retention. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 9, 2022, billed 
with codes 81162, 81403, 81404, 81479, 81408, 81407, 81406, 81405, 81351, 81321, 81317, 81307, 81298, 
81295, 81292, and 81201. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 9, 2022, billed with codes 81162, 81403, 81404, 81479, 81408, 81407, 81406, 81405, 81351, 
81321, 81317, 81307, 81298, 81295, 81292, and 81201.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR panel testing (87511, 87661, 87532, 87653, 
87640, 87481, 87798) provided on February 16, 2023. 
 
You asked the Plan to pay for laboratory services. You say that you have billed for medically necessary testing 
as ordered by the enrollee's provider. The Plan denied your request. The Plan says the standard of care for the 
evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. The PCR panel testing is 
considered excessive testing 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 PCR panel testing is considered excessive testing. Based on this 
information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, 
we decided that the Plan does not have to pay for the urine PCR panel testing (87511, 87661, 87532, 87653, 
87640, 87481, 87798) provided on February 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on February 14, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for nursing facility care. You say that the enrollee could not choose an in-network 
provider. The Plan denied your request. The Plan says this was not authorized. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility care provided on February 14, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive 
interface (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that on the last page of the notes, the doctor states the 
benefits of the Triology and the reason the enrollee is unable to use continuous positive airway pressure 
(CPAP) or BiPAP.  The Plan denied your request. The Plan says the request for a home mechanical ventilator 
set in average volume-assured pressure support (AVAPS) mode with Auto-EPAP (AE) that could be delivered 
by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD.  
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 ventilator. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a home ventilator is not medically necessary. This enrollee has severe COPD with repeated 
hospitalizations for exacerbations with acute on chronic hypercarbic respiratory failure. The enrollee was most 
recently hospitalized in February of this year with arterial blood gas (ABG) documenting severe hypercarbia. 
The enrollee has BiPAP at home, but does not use it regularly, and is noted to have issues with treatment 
compliance. There is no evidence in the medical record of failure of BiPAP as an outpatient. This enrollee may 
benefit from BiPAP with AVAPS as an outpatient, if compliance can be achieved.  Medicare does not cover a 
home ventilator when used at settings that can be provided with BiPAP.   
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has severe air hunger and 
obesity hypoventilation syndrome as well as end stage COPD. It is crucial to provide adequate flow level. The 
Plan denied your request. The Plan says the request for a non-invasive ventilator (NIV) is not medically 
necessary because the documentation does not support that this device meets but does not exceed the enrollee's 
need. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease and obesity hypoventilation 
syndrome. Provided records document that the home ventilator is being requested for use in average volume 
assured pressure support (AVAPS) mode with auto-EPAP (AE) which could be provided by a bilevel positive 
airway pressure (BiPAP) device with AVAPS and a back-up rate. Provided records do not document trial and 
failure of a BiPAP device with AVAPS and a back-up rate. As stated in the Local Coverage Determination 
(L33800): "Ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and payment 
policy requirements preclude FSS payment for devices used to deliver continuous and/or intermittent positive 
airway pressure, regardless of the illness treated by the device. (Social Security Act 1834(a)(3)(A)) This means 
that products currently classified as HCPCS code E0465, E0466, or E0467 when used to provide CPAP or bi-
level PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be 
paid in the FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions 
described in this RAD LCD even though the ventilator equipment may have the capability of operating in a bi-
level PAP (E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for 
conditions described in this RAD policy will be denied as not 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 15, 2022, to 
June 21, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
original DRG was billed appropriately. The Plan denied your request. The Plan says diagnosis code A41.9 
(Sepsis unspecified organism) is not supported in the medical record. As a result, a lower DRG was paid. 
 
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 diagnosis code A41.9 (Sepsis unspecified 
organism). 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 diagnosis code A41.9 (Sepsis unspecified organism) is not 
supported in the medical record. Our physician reviewer found the patient is an 82-year-old female with 
chronic obstructive pulmonary disease on home oxygen who presented to the hospital with shortness of breath. 
Her workup revealed pneumonia vs edema. The patient required oxygen support, however, creatinine, platelets, 
bilirubin were stable/normal, she was not in acute distress, was alert and oriented and had no reported oliguria. 
Sepsis 3 criteria was not met. The patient did not have sufficient evidence of a systemic dysregulated response 
to infection leading to significant organ failure that is life-threatening to support the diagnosis code, A41.9 
(sepsis).   
 
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 provided on June 15, 2022, to June 21, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 12, 2023, to 
January 15, 2023. 
 You asked the Plan to pay for the home health services. You say that you sent in the required NOA. The Plan 
denied your request. The Plan says the NOA was not received timely. Although you contend you sent the NOA 
in on January 12, 2023, there is no evidence of that. As such, this final claim was correctly denied.  
 
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 12, 2023. The NOA was not received by the Plan until March 21, 
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 12, 2023, to January 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a large panel gastrointestinal polymerase chain reaction 
(PCR) test (87507) provided February 23, 2023. 
 You asked the Plan to pay for the laboratory service. You say that please reconsider 87507 - $1780 charge for 
payment with attached medical records related to this date of service. The Plan denied your request. The Plan 
says this service does not meet coverage requirements. 
 
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 87507 is infectious agent detection by nucleic acid 
(deoxyribonucleic acid (DNA) or ribonucleic acid (RNA); gastrointestinal pathogen (eg, Clostridium difficile, 
Escherichia coli (E. coli), Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, 
when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets. 
 
We find that CPT code 87507 is not supported in the medical record. Specifically, the ordering provider is a 
licensed family practice advanced practice registered nurse (APRN), and the test was ordered during an 
outpatient examination with low clinical suspicion for an infectious etiology. 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 a large panel gastrointestinal polymerase chain reaction (PCR) test 
(87507) provided February 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 1, 
2023. 
 
You asked the Plan to pay for procedure code 70450. You say that this was not a bundled charge, and the code 
should be processed for payment. The Plan denied your request. The Plan says payment for code 70450 is 
bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 code 70450 billed for date of service March 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G orthosis. You say that a MyoPro Motion G orthosis is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is 
experimental/investigational. 
 
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 MyoPro Motion G orthosis. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the MyoPro orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for the enrollee's condition or in widespread use for the enrollee's condition based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes 
for the enrollee. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 
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 MyoPro Motion G orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45380 billed for date of service January 26, 
2023. 
 
You asked the Plan to pay for procedure code 45380. You say that the medical records should be reviewed, and 
the claim processed for payment. The Plan denied your request. The Plan says payment for code 45380 is 
bundled into payment for code 45385. 
 
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 45380 
is a column II code to column I code 45385. 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 code 45380 billed for date of service January 26, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator. 
 
You asked the Plan to pre-approve an osteogenesis stimulator. 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 osteogenesis stimulators are 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 an osteogenesis stimulator. Our 
reviewer says that the documentation does not support that the requested device is medically reasonable or 
necessary. Our physician reviewer found the enrollee has a closed fracture of the proximal end of the right 
radius and ulna. A non-spinal electrical osteogenesis stimulator may be covered for treatment of a nonunion of 
a long bone fracture, failed fusion of a joint other than in the spine where a minimum of nine months has 
elapsed since the last surgery or congenital pseudarthrosis. A nonunion of a long bone is defined as 
radiographic evidence (a minimum of two sets of radiographs) that a fracture healing has ceased for three or 
more months prior to starting treatment with an osteogenesis stimulator. In this case, the documentation shows 
slow, progressive healing of the fractured bone. Therefore, the enrollee does not meet criteria for the requested 
device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36620 billed for date of service December 
28, 2022.  
 
You asked the Plan to pay for procedure code 36620. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 36620 is 3. The MAI value for this code is 3. You billed 10 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 36620 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 36620 billed for date of service December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the venipuncture services billed with code 36410 for April 
28, 2022. 
 
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 services are not separately paid. 
 
The Plan must follow Medicare rules. The rules say that services with status indicator N are paid under the 
OPPS, but their payment is packaged into payment for a separately paid service.  
 
We looked at the file and Medicare rules. Billed procedure code 36410 has an OPPS status indicator of N, 
meaning there is no separate payment. Therefore, we decided that the Plan does not have to pay for the 
venipuncture services billed with code 36410 for April 28, 2022.