Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cxbladder test (0012M), provided on March 1, 
2023. 
 
You asked the Plan to pre-approve the Cxbladder test. You say that the service was medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are not 
covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Cxbladder test have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Cxbladder test (0012M), provided on March 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 1, 2023, billed with 
codes 81226, 81479, 81479, 81225, 81227, 81355, 81240, 81241, 81291, 81401, 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are requesting prompt review of the 
medical documentation enclosed and approval of payment for performed services. 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 1, 2023, billed with codes 81226, 81479, 81479, 81225, 81227, 81355, 81240, 81241, 81291, 81401, 
81401.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 3, 2023. 
 You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a 
covered screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on April 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 90935 rendered on March 27, 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 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 
36558. 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 procedure code 90935 rendered on March 27, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to go to rehabilitation to get stronger and 
would like this request to be approved. The Plan denied your request. The Plan says the IRF services requested 
do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Our reviewer found that while the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. Our physician reviewer also found that there is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient RhinAer procedure.  
 
You asked the Plan to pre-approve the RhinAer procedure. You say that medical records were provided to 
support the medical necessity of this procedure. The Plan denied your request. The Plan says the clinical value 
and effectiveness of an outpatient RhinAer procedure in the setting of chronic vasomotor rhinitis have not been 
demonstrated in the peer-reviewed literature. 
 
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 RhinAer procedure. Our reviewer 
says that the requested RhinAer procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record indicates that the enrollee has vasomotor rhinitis.  There is insufficient 
literature to support the safety and efficacy of the requested procedure for the enrollee's clinical condition at this time. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. Therefore, the reviewer found that the requested RhinAer procedure is 
not medically reasonable or 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 RhinAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an outpatient RhinAer procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 additional physical therapy visits.  
 
You asked the Plan to pre-approve the therapy services. You say that the requested therapy services are 
medically necessary. The Plan denied your request. The Plan says you should be independent with a home 
exercise program. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you have previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 18 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 26, 
2023 to April 22, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
were ordered by an in-network provider. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 26, 2023 to April 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on December 12, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain medical records 
showing the ordering physicians intent that the testing be performed. 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 the drug testing services provided on December 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the hospital is going to discharge the enrollee, and 
they cannot function themself. You also say that the enrollee would like to regain their maximum level of 
function by receiving services in an IRF. The Plan denied your request. The Plan says the IRF services you are 
requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that while the medical record supports a need 
for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. Our physician reviewer also found that 
there is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A0427 and A0425 for date of service January 1, 2023. 
 
You asked the Plan to pay for codes A0427 and A0425. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim did not include the required diagnosis code. 
 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 codes A0427 and A0425 are not payable as billed. Specifically, all ambulance transports 
require a dual diagnosis. The claim was not submitted with the required dual diagnosis. Based on this 
information, we decided that Medicare rules for coverage of codes A0427 and A0425 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes A0427 and A0425 for date of service 
January 1, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve transfer surgery (64912). 
 
You asked the Plan to pre-approve the nerve transfer surgery. You say that you need this surgery because you 
have tried physical therapy and have not regained the full use of your arm. The Plan denied your request. The 
Plan says this procedure is experimental. 
 
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 nerve transfer surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the provided records in this case do not clearly document that the nerve transfer 
surgery at issue in this case meets all Medicare criteria for medically reasonable and necessary and safe and 
effective treatment for your condition. 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 nerve transfer surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a nerve transfer surgery (64912).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease pathogen identification panel rendered 
on March 5, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the performance of multiple (>1) FDA-
approved/cleared molecular Infectious Disease pathogen identification tests on the same date of service (DOS) 
should be billed with one procedure code. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with one procedure code. 
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 infectious disease pathogen identification 
panel rendered on March 5, 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 would benefit from an 
admission to an LTACH to regain their maximum prior level of function as well as continue with the 
multidisciplinary approach to care. The Plan denied your request. The Plan says the LTACH admission is 
deemed not medically necessary. 
 
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 
Health Plan. Our reviewer also found that the documentation does not support that LTACH services are 
medically appropriate 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 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 pay for ambulance transportation (A0425, A0426) provided on 
January 8, 2023. You asked the Plan to pay for ambulance transportation. You say that you are requesting reconsideration for 
services advising the claim denied as a duplicate in error and should be paid. The Plan denied your request. The 
Plan says on the date of service, the enrollee was in an inpatient hospital status. 
 
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 codes A0425, A0426 are not supported. Specifically, the records show that the enrollee was 
inpatient from January 7, 2023, to January 19, 2023. Medicare rules say that ambulance services used for 
transportation of a hospital inpatient to another facility is considered part of the inpatient admission and is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of ambulance 
transportation have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
transportation (A0425, A0426) provided on January 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 2, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481, 87653, and 87798 billed for date of 
service February 15, 2023. 
 You asked the Plan to pay for procedure code 87481, 87653, and 87798. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for code 87481, 87653, and 87798 is bundled into 
payment for code 87801. 
 
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 87481, 
87653, and 87798 is a column II code to column I code 87801. 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.  
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, there is no documentation of 
to support the testing of each organism billed for the code. 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 codes 87481, 87653, 87798, and 87801 
billed for date of service February 15, 2023.