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

 
We decided that the Plan does not have to pay for oral brush biopsy CDx testing (88112, 88305, 88312 and 
88361) provided on October 11, 2022. 
 
You asked the Plan to pay for oral brush biopsy CDx testing. You say that these services were medically 
necessary and are supported in the medical record. The Plan denied your request. The Plan says this testing is 
considered investigational/experimental and does not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for oral brush biopsy CDx testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided records in this case consist of the test requisition form, test results and a 
letter of medical necessity from the test vendor. The letter of necessity discusses the test in terms of esophageal 
pathology which was not documented in this case. This case involves a lesion on the right-side gingival tissue 
in the mouth. No other records were provided to document why a standard biopsy would not have been 
adequate in evaluating this enrollee's condition. The test at issue is not supported as medically necessary and 
reasonable by Medicare standards. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oral brush biopsy CDx testing have not been met. Therefore, we decided that 
the Plan does not have to pay for oral brush biopsy CDx testing (88112, 88305, 88312 and 88361) provided on 
October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95955 and 95941 for date of service May 
20, 2022.  
You asked the Plan to pay for procedure codes 95955 and 95941. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says code 95941 is not covered. The clinical value and 
effectiveness of an intraoperative EEG in the setting of lumbar spine surgery 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 pay for procedure code 95955. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found code 95941 reflects (potential) monitoring of more than one procedure at a time. This 
service is not payable as billed. 
 
We find that procedure code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 95955 and 95941 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 95955 and 95941 for date of service May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service December 
14, 2022.  
 
You asked the Plan to pay for procedure code 76942. You say that this was correctly billed as the guidance was 
used with two separate injections.  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 76942 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. The two units were billed for the same patient encounter. Per the coding guidelines, 
a second unit would only be payable in a distinct patient encounter. Based on this information, we decided that 
Medicare rules for coverage of procedure code 76942 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 76942 billed for date of service December 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) and heated humidifier (E0562). 
 
You asked the Plan to pre-approve a CPAP and humidifier. You say that the requested item is a necessity for 
your care. The Plan denied your request. The Plan says rules for payment for CPAP have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that continued coverage of a PAP device requires that 
the treating practitioner must conduct a clinical re-evaluation and document that the beneficiary is benefiting 
from PAP therapy. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP and humidifier have not been met. Specifically, the case record does not document a 
clinical re-evaluation by the treating physician beyond the first 3 months of CPAP therapy. Therefore, we 
decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601) and heated humidifier (E0562).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continuous penicillin 
G. The Plan denied your request. The Plan says an LTACH admission is not medically necessary, and the 
enrollee's needs can be met at an alternate level of care.  
 
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 there is no documentation that was provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where the enrollee is currently receiving care.  
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 LTACH services.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided on August 2, 2022. 
 
You asked the Plan to pay for ambulance services. You say that this should be covered. The Plan denied your 
request. The Plan says that this cannot be paid because the enrollee was in a skilled nursing facility at the time 
of service. 
 
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. While the plan states this denied due to the enrollee being in a skilled nursing 
facility, they have not provided any documentation showing that the enrollee was in a skilled nursing facility 
on the date of service. Therefore, we decided that the Plan has to pay for ambulance services provided on 
August 2, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 provided on September 30, 2022. 
 
You asked the Plan to pay for procedure code 99284. You say that the medical records support the billing of 
code 99284 provided on September 30, 2022. The Plan denied your request. The Plan says the medical records 
do not support the billing of code 99284 provided on September 30, 2022. 
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. 
 
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 procedure code 99284. Our reviewer says that the medical 
records do not support the billing of code 99284 provided on September 30, 2022. Our reviewer found the 
medical records supported a detailed history and a detailed examination but no medical decision making of 
moderate complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99284 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 provided on September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the CGM is needed to help with your diabetes. The 
Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
criteria for CGM coverage are not met. Our physician reviewer found that the provided criteria state that the 
enrollee must have low blood glucose sugar levels or use insulin in order to qualify for CGM coverage; the 
enrollee is not having lows blood glucose sugar levels we are told of nor are they on medications that typically 
cause lows blood glucose sugar levels; the enrollee is not being treated with insulin although her a1c is 10%. 
The criteria for CGM coverage are not met. Although a CGM may indeed help them understand the impact of 
various food choices on their blood glucose sugar levels. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0482) provided on October 3, 2022. 
 You asked the Plan to pay for definitive drug testing. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the number of definitive drug classes that were performed were 
not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules state that definitive urinary drug testing is only covered when 
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 pay for definitive drug testing. Our reviewer says 
that this testing does not meet criteria for payment. Our physician reviewer found the enrollee has diagnoses of 
neck, low back pain, and bilateral shoulder pain as well as medication management of long-term current drug 
therapy. The records sent show presumptive screening test results which are partially inconsistent with 
prescription medications, or history and expected results. Definitive confirmation testing was medically 
necessary for only 1 drug class; that being opiates. This testing does not meet criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of definitive drug testing have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive drug testing (G0482) provided on October 3, 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 requesting an expedited appeal for the denial 
of an IRF admission. You say the enrollee is motivated to improve and would be an excellent rehabilitation 
candidate. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq (J8499). 
 
You asked the Plan to pre-approve Myrbetriq. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Myrbetriq (J8499).   
Benefits for Myrbetriq may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fender shroud repairs. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the item does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve fender shroud repairs.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on August 11, 2022, billed with 
code 73522. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed 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.  

In this case, the CPT Code Manual definition of code 73522 is Radiologic examination, hips, bilateral, with 
pelvis when performed; 3-4 views. 
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the Radiology report documents "2 
views of unilateral hip".  In this case, this is an inappropriate code to report for the service provided, as 
procedure code 73522 represents a bilateral procedure. As such, this procedure cannot be verified. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on August 11, 2022, billed with code 73522.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services billed with Patient-Driven 
Groupings Model (PDGM) 2HB11 provided on December 18, 2021, to January 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as billed 
 
The Plan follows Medicare rules. Medicare rules say that home health services must be billed with an 
appropriate PDGM. 
 
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 home health services as billed. Our 
reviewer says that the services billed are not supported. Our physician reviewer found the enrollee was 
receiving home health care services. The documentation supports that the enrollee was receiving services as a 
referral from the community. The documentation indicates the hospitalization that proceeded the home health 
services were rendered at an observational level of care. The documentation does not support the correct PDPM 
HIPPS code submitted.  

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 home health services as billed have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services billed with Patient-Driven Groupings Model 
(PDGM) 2HB11 provided on December 18, 2021, to January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641 and 87653 billed for 
date of service December 28, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641 and 87653. You say that these services are 
supported in the medical record. The Plan denied your request. The Plan says these services are not supported 
for separate reporting. 
 
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 codes 87150, 87481, 87641 and 87653 are column II codes to column I 
codes 87500 and/or 87801; however, 87150, 87481, 87641 and 87653 were each billed with a modifier.  
 
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 procedure codes 87150, 87481, 87641 and 87653. Our 
reviewer says that these services are not supported for separate reporting in this case. Our reviewer found the 
laboratory report does not include documentation to support modifier XU (unusual non-overlapping service) 
for the procedures at issue. These services would be included in codes 87801 and 87500, reported for the same 
date. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87641 and 87653 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641 and 87653 billed for 
date of service December 28, 2022.