Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit provided on November 23, 2022.  
 
You asked the Plan to pay for the office visit. You say that this was a medically necessary visit. The Plan 
denied your request. The Plan says that this claim was billed with only one diagnosis for obesity due to excess 
calories. Medicare does not pay for any treatments for obesity alone, as noted in NCD 100.1. 
 
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 NCD cited by the Plan reveals that the rule has been 
misinterpreted. This NCD includes criteria that are specific to bariatric surgery. The office visit at issue was in 
no way related to bariatric surgery. The cited NCD cannot be construed to non-cover all services for the 
treatment of obesity. We find that the Plan has not provided any other applicable rule to support the denial of 
payment in this case.  Therefore, we decided that the Plan has to pay for the office visit provided on November 
23, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on December 
13, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
December 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73620 billed for date of service February 2, 
2023. 
 You asked the Plan to pay for procedure code 73620. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 73620 is bundled into payment for code 
73630. 
 
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 73620 
is a column II code to column I code 73630. 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 73620 billed for date of service February 2, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that this is medically necessary testing. 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 October 10, 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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted for surgical repair of a hip fracture after a fall and was transferred to skilled nursing on 
May 26, 2023. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that an epidural steroid injection is 
medically necessary. You say the patient is in active physical therapy with little to no improvement. The Plan 
denied your request. The Plan says the requested epidural steroid injection does not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 epidural steroid injection. Our 
reviewer says that the requested epidural steroid injection is not considered medically necessary. Our physician 
reviewer found in this case; the previous epidural steroid injection provided only 20% relief of pain for a period 
of two days. The review has determined that the requested epidural steroid injection does not meet the 
Medicare LCD coverage criteria. 
 
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 epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical shoulder arthroscopy (procedure code 29826) rendered on 
December 7, 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 the records do not 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 
code 29826 is "Arthroscopy, shoulder, surgical; decompression of subacromial space with partial 
acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to 
code for primary procedure)." 
 
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 supported by the medical records. Our reviewer found that the procedure details cite the scope 
was moved to the subacromial space and a thorough bursectomy was performed. A decompression was 
performed with the shaver. The documentation does reasonably corroborate that a partial acromioplasty and 
associated coracoacromial ligament having been released. Therefore, the records do support that CPT 29826 
was rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical shoulder arthroscopy (procedure code 29826) rendered on December 7, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on January 5, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation treatment management (procedure code 77247) 
rendered on January 19, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the claim does not indicate the number of fractions. 
 
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 77247 is "Radiation treatment management, 5 
treatments." 
 
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 weekly management billing 
encompasses reviewing patients prescribed dose, treatment set-up (usually weekly or daily imaging) and 
seeing patient at least once during the 5-day window of that week of treatment (for daily treatment), allowing 
for a minimum of 3 fractions during hat window at the end of treatment. For this case, that service was denied 
due to insufficient records supporting that service. There are no records or radiation delivery, no patient visit 
under treatment by radiation oncologist, or evidence of radiation oncologist involvement in the weekly 
management. The denied services are not supported. 
 
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 radiation treatment management (procedure code 77247) rendered on January 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial inpatient evaluation and management (EM) 
services provided on February 3, 2023.  
 
You asked the Plan to pay for the EM services. You say that this payment should not be included in any other 
services rendered on this date.  The Plan denied your request. The Plan says this was not billed correctly to 
allow payment for the services rendered.   
The Plan must follow Medicare rules. Medicare rules say that payment can only be made for services rendered 
to an incarcerated individual when certain criteria are met. If these criteria are met, modifier QJ is required.  
 
We looked at the file and Medicare rules. The enrollee was brought to the facility by the police. The inpatient 
claim reports discharge status code 21, meaning that the enrollee was discharged to law enforcement/the courts. 
The enrollee is therefore considered to be incarcerated/in custody. Payment could only be made if modifier QJ 
is used. Based on this information, we decided that Medicare rules for coverage of the EM services have not 
been met. Therefore, we decided that the Plan does not have to pay for the initial inpatient evaluation and 
management (EM) services provided on February 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (K0108, 
E2311, E2313, and E2377). 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not a medical need to control these power options through the joystick. 
 
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 items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested 20Deg active reach system (K0108) is non-covered as it serves no primary 
medical purpose. The provided records document that the enrollee has 5/5 bilateral upper extremity elbow and 
wrist strength and right grip of 25 pounds and left grip of 48 pounds thus indicating the enrollee has adequate 
upper extremity strength and function to operate the wheelchairs power options with their own switches.  
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional power wheelchair accessories (K0108, E2311, E2313, and E2377).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a respiratory panel rendered on December 20, 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 this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. We find that the various denied CPT codes are not supported in the 
medical record. Specifically, the testing at issue in this case should be reported with one code only. 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 a respiratory panel rendered on December 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided on April 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 (0037U) provided on April 7, 2021.
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 9, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab 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 
February 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (87631, 94761, 99072) provided on May 19, 
2022 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Codes 94761, and 99072 are bundled with another service billed and are not separately payable. 
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 (87631, 94761, 99072) provided on 
May 19, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for six additional units of procedure code 88377 billed for date 
of service January 13, 2023.  
 
You asked the Plan to pay for procedure code 88377. You say that these services were necessary and were 
reported appropriately. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88377 is 5. The MAI value for this code is 3. You billed 11 total units of 
this code, exceeding the MUE. You did not provide all the required evidence showing that the excess units 
were actually provided, were correctly coded, and were medically necessary. Based on this information, we 
decided that Medicare rules for coverage of procedure code 88377 have not been met. Therefore, we decided 
that the Plan does not have to pay for six additional units of procedure code 88377 billed for date of service 
January 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on December 
27, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on December 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 25, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 
is a column II code to column I code 70496. 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 billed for date of service August 25, 2022.