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

 
We decided that the Plan does not have to pay for procedure codes 99072, 94761, and 87631 billed for date of 
service November 21, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services are 
not payable.  
 
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 99072 has a status indicator of B, and procedure code 94761 has a status indicator 
of T on the Physician Fee Schedule. This means that the codes are not separately payable. A review of the 
claim does not show that the required unique identifier for code 87631was reported. 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 codes 99072, 94761, and 87631 billed for date of service 
November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office evaluation and management (EM) services and 
ultrasound provided on November 25, 2022, billed with codes 99215 and 76770, respectively. 
 
You asked the Plan to pay for the EM services and ultrasound as billed. You say that this should be paid as 
billed.  The Plan denied your request. The Plan says the codes at issue are 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 code 99215 is Office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is 
spent on the date of the encounter. The manual definition of 76770 is ultrasound, retroperitoneal (eg, renal, 
aorta, nodes), real time with image documentation; complete.  
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 EM services and ultrasound as billed. Our reviewer says 
that the documentation does not support the billed codes. Our reviewer found review of the records do not 
reveal medical decision making of high complexity. As such, code 99215 is not supported. In addition, the 
documentation does not support code 76770, as there is another code that more adequately describes the areas 
reviewed in this imaging.  
 
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 EM services and ultrasound as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the office evaluation and management (EM) services and 
ultrasound provided on November 25, 2022, billed with codes 99215 and 76770, respectively.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93458, G0500) provided on August 19, 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 use of codes 93458 
and G0500 is not supported by the records provided. Our reviewer found that the documentation consists of a 
follow up visit with some tests and results. There is no documentation of a procedure where a cardiac 
catheterization was performed, or sedation for a gastrointestinal endoscopic procedure. 
 
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 the services (93458, G0500) provided on August 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services are necessary for the enrollee as they 
require around the clock nursing care and max assist with daily activities. The Plan denied your request. The 
Plan says the services the enrollee requires are called custodial care and are not a Medicare covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on January 23, 
2023. 
 
You asked the Plan to pay for the general health panel. The Plan denied your request. The Plan says this service 
is not covered. 
 
The Plan must follow Medicare rules. The rules say that a GHP (code 80050) is not covered or paid for by 
Medicare.   
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on January 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing denoted by procedure codes 81265 and 
81266, billed for date of service June 8, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue have been billed correctly. The 
Plan denied your request. The Plan says the genetic tests at issue are not a covered benefit. 
 
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. The rules also say that tests performed to measure the quality of a process do 
not provide information to diagnose or treat a patient illness or injury as defined in the Medicare benefit 
category. 
 
We looked at the file and Medicare rules. The know error DNA Specimen Provenance Assay is a statutorily 
excluded test. Medicare records indicate that the DNA Specimen Provenance Assignment genetic test has not 
been approved through the MolDX contractor. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
genetic testing denoted by procedure codes 81265 and 81266, billed for date of service June 8, 2022.
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 December 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. 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 
December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee needs the home ventilator. 
Medical records are attached to support medical necessity. The Plan denied your request. The Plan says the 
request for continued use of a non-invasive ventilator (NIV) is not medically reasonable and necessary. The 
documentation indicates that this device is being used solely for AVAPS-AE mode, and thus it is being used 
solely as a respiratory assist device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD with chronic 
respiratory failure, unspecified whether with hypoxia or hypercapnia, as well as congestive heart failure, 
diabetes, and morbid obesity. The case file contains an ABG from December 27, 2017, when the enrollee was 
in shock (cardiogenic versus septic). The enrollee has been wearing BiPAP at night. A device mode of AVAPS 
AE is selected. A ventilator is not eligible for reimbursement for any of the conditions described in this RAD 
LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP (E0470, 
E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described 
in the Medicare RAD policy will be denied as not reasonable and necessary. A BiPAP device with AVAPS 
(coded as E0471) was not requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the presumptive drug testing and the definitive drug testing of 15-21 
drug classes provided on September 30, 2022, billed with 80307 and G0482 respectively. 
 
You asked the Plan to pay for the drug testing as billed. You say that this should be paid.  The Plan denied your 
request. The Plan says that only 12 drug classes were tested so another code is more appropriate for the 
definitive testing. The presumptive testing was paid to the same or another provider on the same date, so it 
cannot be paid to this provider.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the lab report supports that 15 drug classes (as defined by the CPT 
Manual) were tested which supports the use of code G0482. In regard to 80307, the Plan has indicated that this 
was reimbursed on the same date to the same or different provider. However, the file did not include evidence 
of this payment. As such, the denial of payment of both codes is not substantiated. Therefore, we decided that 
the Plan has to pay for the presumptive drug testing and the definitive drug testing of 15-21 drug classes 
provided on September 30, 2022, billed with 80307 and G0482 respectively.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service October 29, 2022. 
 
You asked the Plan to pay for code 99285. You say that the original code billed was appropriate and the 
downcoding by the Plan was incorrect. The Plan denied your request. The Plan says the billed level of service 
(code 99285) was adjusted to code 99284 consistent with the medical information. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive 
examination; and medical decision making of high complexity. 
 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 99285. Our reviewer says that the Plan was justified in 
downcoding this service to 99284. Our reviewer found a comprehensive history requires a chief complaint, an 
extended history of present illness, a review of all additional body systems and a complete past, family and 
social history. A comprehensive examination requires a general multisystem examination or a complete 
examination of a single organ system and medical decision making of high complexity requires 2 out of 3 of an 
extensive number of diagnoses or management options, an extensive amount and complexity of data reviewed 
and high risk of complication. The provided records in this case for date of service 10/29/2022, document a 
chief complaint, an extended history of present illness, a review of all additional body systems and a complete 
past, family and social history. The provided records document a general multisystem examination but do not 
document 2 out of 3 of an extensive number of diagnoses or management options, an extensive amount and 
complexity of data reviewed and high risk of complication. The provided records do not support CPT code 
99285; the level of service documented in the provided records is more accurately represented by code 99284 
(moderate level of decision making).   
 
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 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service October 29, 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 you are unable to stand on your own and need 
physical therapy and occupational therapy to get stronger. The Plan denied your request. The Plan says the 
denial of IRF care is correct. 
 
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. 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring (procedure code 
G0453) rendered on May 26, 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 that Healthcare Common Procedure Coding System (HCPCS) code G0453-59 remains not 
supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that 
procedure code G0453 is supported. The record contains evidence that remote intraoperative neuromonitoring 
was performed. This is not part of procedure code 95955 because the record does not support that a diagnostic 
electroencephalogram (EEG) was performed during non-intracranial surgery; an EEG interpretation is not 
documented in the record. Only G0453 is supported. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
continuous intraoperative neurophysiology monitoring (procedure code G0453) rendered on May 26, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high dose rate electronic brachytherapy (0394T), 
therapeutic radiology simulation-aided field setting; simple (77280) and therapeutic radiology simulation-aided 
field setting; complex (77290). 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that you do not know why the procedure 
is denied but you need to get the treatment started. The Plan denied your request. The Plan says the records do 
not show that you have undergone clinic staging, consideration for resection of the remaining lesion, or 
consideration for alternate treatment options. The request 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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found you have a skin lesion on your nose. The records do not show you have undergone 
clinic staging or been considered for excision of the lesion. The request is 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 electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a high dose rate electronic brachytherapy (0394T), therapeutic radiology 
simulation-aided field setting; simple (77280) and therapeutic radiology simulation-aided field setting; complex 
(77290).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external bone growth stimulator. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no indication in the records that the enrollee is having three or more levels 
fused. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 stimulator. Our reviewer says that 
the requested stimulator is not medically reasonable or necessary. Our physician reviewer found that the 
enrollee has a diagnosis of Spinal stenosis, lumbar region without neurogenic claudication. The provider states 
that the enrollee has signs of osteopenia, and is to undergo a lumbar fusion, and will need an external bone 
growth stimulator to reduce her risk of pseudoarthrosis. The enrollee does not meet the coverage criteria for an 
external bone growth stimulator, as established by NCD 150.2. 
 
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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an external bone growth stimulator.