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 May 31, 2023, billed with 
codes 81209, 81298, 81305, 81307, 81311, 81317, 81320, 81321, 81334, 81339, 81345, 81216, 81223, 81238, 
81241, 81242, 81249, 81250 and 81279. 
 
You asked the Plan to pay for the genetic 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 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 
May 31, 2023, billed with codes 81209, 81298, 81305, 81307, 81311, 81317, 81320, 81321, 81334, 81339, 
81345, 81216, 81223, 81238, 81241, 81242, 81249, 81250 and 81279.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. You say that this type of radiation therapy reduces the radiation dose 
exposure to surrounding organs. The Plan denied your request. The Plan says that there is not enough research 
showing that the enrollee's type of cancer responds better to PBRT than to Intensity-Modulated radiation 
therapy (IMRT). 
 
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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that while some may argue that it is standard practice to treat prostate cancer with proton 
therapy, both American Society of Radiation Oncology (ASTRO) and the National Comprehensive Cancer 
Network (NCCN) guidelines recommend against routine use of proton therapy. Proton therapy may or may not 
be better than intensity-modulated/image-guided radiation therapy (IMRT/IGRT) and would arguably exceed 
the enrollees medical needs. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve proton beam radiation therapy (PBRT).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation codes A0425 and A0427 billed for date of 
service March 13, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was not an inpatient at the time of 
transport. The Plan denied your request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The enrollees claim information shows that the enrollee was receiving 
inpatient behavioral health care at the time the transportation services were provided. The services should be 
bundled to the hospital. 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 transportation codes 
A0425 and A0427 billed for date of service March 13, 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 July 17, 2023, and billed with codes 87481, 87652, 87798, and 87801. 
 
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 July 17, 2023, and billed with codes 87481, 87652, 87798, and 87801.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Holter monitor. 
 
You asked the Plan to pre-approve a Holter monitor. You say that the item is necessary. The Plan denied your 
request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order for the supplies provided in this case. No physician order 
for the requested equipment was provided. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pre-approve a 
Holter monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on April 24, 2023. 
 
You asked the Plan to pay for the medical services. You say that the diagnosis codes were based on the 
procedure, not anesthesia. 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 R10.13 has an Excludes1 note in relation to R12. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on April 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head or brain 
(70450).  
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee has a history of fall with head strike. 
You say the enrollee also has a history of abnormal CT scan of the brain. The Plan denied your request. The 
Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the medical necessity of the requested CT of 
the brain has not been established in the records provided. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the head or brain (70450).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interrogation device (procedure code 93296) rendered on 
October 17, 2022. 
 
You asked the Plan to pay for the device. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim does not meet the coding standards. 
 
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 93296 is "Interrogation device evaluation(s) (remote), up 
to 90 days; single, dual, or multiple lead pacemaker system, leadless pacemaker system, or implantable 
defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical 
support and distribution of results." 
 
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 device. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the procedure report describes, remote 
interrogation was performed on October 17, 2022. Per CPT guidelines for CPT 93296 - "Codes 93293 - 93296 
are reported no more than once every 90 days.  Do not report 93293 - 93296 if the monitoring period is less 
than 30 days."  In this case, verification cannot be made for service performed more than 30 days. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pay for an interrogation device (procedure code 93296) rendered on October 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 2, 2023. 
 
You asked the Plan to pay for the medical services. You say that you believe this claim was denied due to 
timely filing rules. 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 J96.00 has an Excludes1 note in relation to R06.02. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on February 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service June 16, 
2023. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
June 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair or walker with wheels and a seat. 
 
You asked the Plan to pre-approve a power wheelchair or walker with wheels and a seat. You say that the items 
are necessary The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order for the supplies provided in this case. No physician order 
for the equipment was provided. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair or walker with wheels and a seat.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 71045, 74174, 93880, and G1004 rendered 
from August 15, 2022, to August 17, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says no records have been received to support the services 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 the denied codes is: 
 
CPT 71045: 
 
Radiologic examination, chest; 2 views  
CPT 74174: 
 
Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast 
images, if performed, and image postprocessing 
 
CPT 93880: 
 
Duplex scan of extracranial arteries; complete bilateral study 
 
Healthcare Common Procedure Coding System (HCPCS) G1004: 
 
Clinical decision support mechanism national decision support company, as defined by the medicare 
appropriate use criteria program 
 
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 none of the denied exams include 
a report in the submitted records. 
 
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 codes 71045, 74174, 93880, and G1004 rendered from August 15, 2022, to August 
17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PuraPly wound skin substitute. 
 
You asked the Plan to pre-approve PuraPly wound skin substitute. You say that the PuraPly wound skin 
substitute is medically necessary. The Plan denied your request. The Plan says the requested PuraPly wound 
skin substitute is 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 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 PuraPly wound skin substitute. Our 
reviewer says that the requested PuraPly wound skin substitute is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee with leg venous disease and recent treatment 
for cellulitis and closure of the right greater saphenous vein followed by development of an open wound treated 
with collagen and compression wrap. The provided documentation did not clearly show a failure of conservative treatments, nor is there current literature or guidelines supporting this specific product over other 
similar grafting products that are the Food and Drug Administration (FDA) approved. Therefore, without 
sufficient support for this request, the PuraPly wound skin substitute will not be considered medically 
necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PuraPly wound skin substitute have not been met. Therefore, we decided that 
the Plan does not have to pre-approve PuraPly wound skin substitute.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95886 and 95907 rendered on June 9, 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 denied codes remain 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 the denied codes is: 
 
CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
CPT 95907: 
 
Nerve conduction studies; 1-2 studies 
 
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 in terms of CPT 95886, per the 
CPT code description "done with nerve conduction, amplitude and latency/velocity study." In this case, nerve 
conduction is not supported in medical record; therefore, this procedure cannot be verified. 
 
In terms of CPT 95907, the medical records describe pedicle screw stimulation. For CPT 95907, in a nerve 
conduction study, several flat metal disc electrodes are taped or pasted to your skin. A shock-emitting electrode 
is placed directly over the nerve to be studied. A recording electrode is placed over the muscles supplied by 
that nerve. Several brief electrical pulses are sent to the nerve. Nerve conduction studies would not be reported 
for pedicle screw stimulation.  
 
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 95886 and 95907 rendered on June 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on October 29, 2020. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 
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 the practitioner services provided have 
been met. Specifically, no medical records have been provided for review. Therefore, we decided that the Plan 
does not have to pay for practitioner services provided on October 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing provided June 25, 2023, billed 
with codes 87150-59 x12, 87798-59 x13, 87481-59 x4, 87640-59, 87653-59. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says the PCR testing is 
considered excessive testing and not medically necessary. The unbundling of lab codes for PCR panel testing is 
not appropriate. 
 
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. The standard of care for the evaluation of urinary incontinence is 
urinalysis with urine culture and sensitivity. This was a 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 laboratory testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel testing 
provided June 25, 2023, billed with codes 87150-59 x12, 87798-59 x13, 87481-59 x4, 87640-59, 87653-59.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 23, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that you do not understand why payment for 
this claim was recouped. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on January 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 88305 for date of service June 7, 2023. 
 
You asked the Plan to pay for code 88305. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the diagnosis code at issue was the only diagnosis on this claim. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code R85.7, defined as 
abnormal histological findings in specimens from digestive organs and abdominal cavity. Review of the file 
shows that this claim was billed with an R diagnosis code in the first-listed diagnosis position. This diagnosis 
was the only diagnosis on the claim. The claim is not payable as billed. Based on this information, we decided 
that Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan does not 
have to pay for code 88305 for date of service June 7, 2023.