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

 
We decided that the Plan does not have to pay for procedure code 36246 rendered on February 24, 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 this is not separately reportable. 
 
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 36246 is "Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the code in question is not 
separately reportable. The records provided document the performance of balloon angioplasty of the right tibio-
peroneal trunk coded and covered as CPT code 37228.  Codes for lower extremity arterial intervention 
including tibial angioplasty as coded with 37228, are bundled codes incorporating the work performed in 
achieving selective access to image and treat. 
 
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 36246 rendered on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service May 4, 2023, to May 
7, 2023. 
 
You asked the Plan to pay for code 99233. You say that medical records were provided to support payment. 
The Plan denied your request. The Plan says code 99233 is not supported by the medical record. The medical 
records don't support a high level of medical decision making or total time required of the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is Subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. When using total time on the date of the 
encounter for code selection, 50 minutes must be met or exceeded.  
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 code 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found the enrollee is an 81-year-old female who was treated on 
the dates of service May 4, 2023, to May 7, 2023. The records for these dates describe the enrollee with 
diagnosed colitis based on symptoms and computed tomography (CT) scan results who was already started on 
antibiotics, with minimal abdominal tenderness, not appearing toxic, without surgery recommended or planned 
and with stable vitals. Code 99233 is not sufficiently supported in the documentation from these dates as 
the medical records don't support a high level of medical decision making or total time required of the code 
billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for dates of service May 4, 2023, to May 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial lower denture (D5226) provided by an out-of-
network provider on February 2, 2023. 
 
You asked the Plan to pay for the dental service. You say that you have gone to the same provider for years and 
you never received and correspondence from the Plan on the change in coverage. The Plan denied your request. 
The Plan says the dental service was received from an out-of-network provider and are not covered by your 
supplemental benefits. Also, it was verified that the Annual Notice of Changes was shipped out to you on 
September 7, 2022. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental service from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested item or service is not covered under this 
benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to 
pay for a partial lower denture (D5226) provided by an out-of-network provider on February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on January 13, 2023, and billed with codes 87481, 87500, 87640, 87799, 87798, 87652, and 87900. 
 
You asked the Plan to pay for the urine PCR panel testing. 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 testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on January 13, 2023, and billed with codes 87481, 87500, 87640, 87799, 87798, 87652, 
and 87900.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 19, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and are 
covered by Medicare. 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 provided on April 19, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service May 25, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and are 
covered by Medicare. 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 billed for date of service 
May 25, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency care provided on May 18, 2023. 
 
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 items/services at issue were 
reimbursed by the Plan on June 30, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/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 emergency care provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99213) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an office visit an office visit 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 
an office visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TissueCypher test billed for date of service January 27, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the test is a covered benefit. The Plan denied 
your request. The Plan says the test remains unproven. 
 
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 pay for the billed services. Our physician reviewer 
found that the TissueCypher testing was provided for Barrett's esophagus. TissueCypher is not standard of care 
and not medically 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 the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the TissueCypher test billed for date of service January 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you have provided medical 
records to show the necessity of this item. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 for date of service January 12, 2023. 
 
You asked the Plan to pay for procedure code 88305. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  In this case, we have confirmed that I83.218 has an Excludes1 note in relation to I87.331. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for procedure code 88305 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 88305 for date of service January 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Aurora Spine ZIP Interspinous Fixation device 
(22612, 22840). 
 
You asked the Plan to pre-approve an Aurora Spine ZIP device. 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 an Aurora Spine ZIP device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the aurora zip device is experimental for spinal fusion. More research is 
needed.  
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 Aurora Spine ZIP device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Aurora Spine ZIP Interspinous Fixation device (22612, 22840).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service June 19, 
2023. 
 You asked the Plan to pay for procedure code 99283. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 99283 is bundled into payment for 
code 99284. 
 
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 99283 
is a column II code to column I code 99284. 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 99283 billed for date of service June 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided from January 5, 2022, to January 
17, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that your claims continue to get rejected. The Plan 
denied your request. The Plan says this claim was not submitted within the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for chiropractic care was not filed until May 10, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for chiropractic care provided from January 5, 2022, to January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 
April 27, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479, and 81238.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on May 30, 2023, billed with 
codes 87641, 87640, 87653, 87481 and 87798 
. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. 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 a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on May 30, 2023, billed with codes 87641, 87640, 87653, 87481 and 87798 
.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on June 26, 2023, billed with 
codes 87481, 87500, 87640, 87652, 87900, 87799 and 87798 x13. 
 
You asked the Plan to pay for the laboratory testing billed. You say that this test was ordered based upon the 
treating physicians clinical training and medical necessity. 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. 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 testing 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on June 26, 2023, billed with codes 87481, 87500, 87640, 87652, 87900, 87799 and 87798 x13.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 93971 rendered on April 26, 
2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation does not support that excess units were provided. 
 
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 93971 is "Duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that a review of the records revealed 
one report of unilateral left leg ultrasound was done. Thus, the billing for one unit of 93971 was appropriate but 
there is no evidence to suggest more than one unit that date was done. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for two units of procedure code 93971 rendered on April 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service August 10, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was billed correctly. The Plan denied 
your request. The Plan says the billed code cannot be verified. 
 
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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. We find that 11 units of CPT 
code 87798 are not supported in the medical record. The records show that over 25 organisms/genes were 
tested in this case. The records do not identify which 11 organisms are associated with code 87798. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 87798 billed for date of service 
August 10, 2022.