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

 
We decided that the Plan does not have to pay for the genetic testing provided on June 7, 2023, billed with 
codes 81226, 81401, 81240, 81241, 81225, 81227, 81230, 81231, 81291, 81328, 81355 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was 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 
June 7, 2023, billed with codes 81226, 81401, 81240, 81241, 81225, 81227, 81230, 81231, 81291, 81328, 
81355 and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation to be provided by an out-of-network 
(OON) radiation oncologist.  
 
You asked the Plan to pre-approve an evaluation. You say that there are no in network providers who perform 
Cyber Knife. The Plan denied your request. The Plan says their original decision to deny coverage was correct. 
 
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 
an evaluation to be provided by an out-of-network (OON) radiation oncologist.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination of the toe(s) (x-ray) (73660) provided 
on July 19, 2023. 
 
You asked the Plan to pay for the x-ray. You say that CPT code 73660 was billed correctly and should be paid. 
The Plan denied your request. The Plan says that CPT codes 73660 and 99283 cannot be billed separately 
because they are both packaged into payment for CPT code 99283.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 73660 is not supported in the medical record. Specifically, codes 73660 and 99283 have 
a status indicator of Q1 in the Outpatient Prospective Payment System (OPPS). Q1 codes are packaged and are 
not separately paid when billed with another code with an OPPS indicator of S, T, or V. In this case, code 
99283 that was billed and paid on the same date of service has a status of J1 and V. Therefore, codes 73660 and 
99283 are not separately paid. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for radiologic examination; 
toe(s), minimum of 2 views (x-ray) (73660) provided on July 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and x-rays of the neck, spine, and upper 
gastrointestinal tract billed with codes 74230, 99214, 74240, and 72040 provided on March 7, 2023. 
 
You asked the Plan to pay for the office visit and x-rays. You say that the services were billed correctly, and 
the claim should be paid. The Plan denied your request. The Plan says POS 11 (office setting) was billed, 
however, documentation received does not support that the services were performed in an office setting but 
rather in a mobile setting. 
 
Medicare rules say that for services in a mobile unit, the POS code assigned should either be the POS code for 
the entity the mobile unit is serving, or POS code 15. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of office visit and x-rays have not been met. Therefore, we decided that the Plan does not have to pay 
for the office visit and x-rays of the neck, spine, and upper gastrointestinal tract billed with codes 74230, 
99214, 74240, and 72040 provided on March 7, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Positron emission tomography (78815). 
 
You asked the Plan to pre-approve a PET. You say that you trust your physician that is referring this service for 
testing. The Plan denied your request. The Plan says that the notes do not show documentation that you have a 
cancer diagnosis, so this request has been denied. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET. Our reviewer says that you need 
this medical item. Our physician reviewer found the mass structure on the CT chest as well as history of weight 
loss and hemoptysis, there are concerns for a solid tumor.  The computed tomography the chest was not able to 
provide a clear diagnosis and prior to invasive procedure like a biopsy, PET scan is medically reasonable for 
next stage of work-up. 
 
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 PET have not been met. Therefore, we decided that the Plan has to pre-
approve a Positron emission tomography (78815).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0326U) provided on May 30, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (0326U) provided on 
May 30, 2023.
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 enrollee needs the 24/7 hour care that 
a LTACH staff can accommodate. The Plan denied your request. The Plan says the records do not show that 
the physician's expect the enrollee will get better with LTACH. 
 
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 is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another.  
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Wheelchair Van - Non-Emergency Transportation. 
 
You asked the Plan to pre-approve non-emergency transportation.. The Plan denied your request. The Plan says 
services that are medically necessary are covered using criteria and guidelines to determine medical necessity, 
there are no records showing medical necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we 
decided that the Plan does not have to pre-approve a Wheelchair Van - Non-Emergency Transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 35201 performed 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 CPT 35201 cannot be reimbursed, as it is inherent to the primary vascular procedure. 
 
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 35201 is "Repair blood vessel, direct; neck." 
 
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 the medical records. Our reviewer found that it is not appropriate to bill CPT 
35201 with CPT 33986. The medical documentation does not support CPT 35201 was done in addition to the 
primary procedures.  
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 code 35201 performed on April 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies have not proven that this procedure is helpful for treatment. 
 
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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no magnetic resonance imaging (MRI) showing only modic changes without facet 
degenerative joint disease or stenosis. The cause of the pain is not clear. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitoring (CGM) sensor (A9276) 
provided on April 17, 2023. 
 
You asked the Plan to pay for the CGM sensor. You say that the enrollee should not have to pay for the service 
because it has always been a 15% coinsurance any time other products were ordered. The Plan denied your 
request. The Plan says the requested item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that products reviewed by the PDAC which do not 
meet the DME benefit category requirements must be coded as A9276, A9277, A9278, or A9279 and will be 
denied as non-covered (no Medicare Benefit). 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CGM sensor have not been met. Therefore, we decided that the Plan does not have to pay for a 
continuous glucose monitoring (CGM) sensor (A9276) provided on April 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery assistant services provided on June 6, 2023. 
 
You asked the Plan to pay for the billed services. You say that the billed codes are payable. The Plan denied 
your request. The Plan says the provider was not authorized for assistant services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists is a physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service was a physician, PA, 
NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types 
of practitioners. Therefore, we decided that the Plan does not have to pay for surgery assistant services 
provided on June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care visit involving evaluation 
and management (E/M) (99309) provided March 20, 2023. 
 
You asked the Plan to pay for the E/M subsequent nursing facility care visit . You say that you use CMS 
guidelines for billing and coding and after reviewing the claim it has been billed correctly per this guideline. 
The Plan denied your request. The Plan says the service at issue was not billed with the required modifier to 
allow separate payment within the global surgery period.  
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 11042 
provided on March 20, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care visit 
involving evaluation and management (E/M) (99309) provided March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for March 30, 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 billed units of procedure code 87481 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 4 units of CPT code 87481 are not supported in the medical record. The medical record only 
supports 3 units of CPT code 87481. 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 procedure code 
87481 billed for March 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
October 7, 2022, and billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 
87641, 87651, 87653, 87661, 87798, and G0452. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing 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 urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on October 7, 2022, and billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 
87591, 87641, 87651, 87653, 87661, 87798, and G0452.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power scooter, and delivery and set up provided on 
February 5, 2023. 
 
You asked the Plan to pay for the power mobility device. You say that you were advised by a plan 
representative that this would be covered under your policy. You say that you were advised to make the 
purchase and submit a claim for reimbursement. You also say that you feel you should be reimbursed. The Plan 
denied your request. The Plan says features of a scooter intended for use outside the home are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the power scooter, and delivery and set up provided on February 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the recliner chair purchased on July 12, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the recliner chair purchased on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies billed with code A4239 for March 15, 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery with the  
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. The 
submitted proof of delivery has a delivery date that does not match the billed date of service. 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 supplies billed with code A4239 for March 15, 2023.
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 enrollee's condition will improved in 
the LTACH setting. The Plan denied your request. The Plan says the enrollee's continued care needs include 
ventilator weaning, IV antibiotics and tube feeds being provided in the current acute care setting. 
 
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 is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another.  
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional mileage. You say that you need transportation to medical 
appointments. The Plan denied your request. The Plan says the requested transportation exceeds your mileage 
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 routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. In this case the requested trip is greater 
than 50 miles of driving distance. 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 
additional miles for routine transportation beyond the Plan's 50-mile limit.