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

 
We decided that the Plan does not have to pay for  genetic testing services 87500, 87641, 87798, 87491, 87496, 
87511, 87529, 87532, 87563,87591,87661, 87481, 87651, 87653 provided December 1, 2022. 
 
You asked the Plan to pay for  genetic testing. You say that you do not personally see patients and is dependent 
on receiving patient information from the ordering provider. The Plan denied your request. The Plan says 
additional information is needed to consider this charge.  
 
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 genetic testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found he review indicates that the enrollee had urinary tract infection (UTI) symptoms. Urinalysis 
with urine culture is the gold standard for detection of urinary tract infection. The review has determined that 
the items/services at issue in this case were 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for  genetic testing services 87500, 87641, 87798, 87491, 87496, 87511, 87529, 87532, 
87563,87591,87661, 87481, 87651, 87653 provided December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DCISionRT testing rendered on December 27, 2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this test is still undergoing clinical trials. 
 
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 the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that DCISion RT is still investigational. While DCISion RT test has been validated in multiple studies including an observational study of 455 patients and a randomized clinical trial of 700 patients, there are still 
lack of studies and undergoing clinical trials. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for DCISionRT testing rendered on December 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on December 28, 2022, billed with 
codes 29819-AS-RT and 29826 AS-RT. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that procedure code 29819 is not eligible for an 
assistant. The plan also says that procedure code 29826 is an add-on code that was billed without an 
appropriate primary procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 29819-AS-RT. The Medicare Fee Schedule Database contains a surgical 
indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not 
medically necessary and will not be paid. Procedure code 29826 AS-RT is an add on code and cannot be billed 
without a valid primary procedure. Based upon this information, we find that Medicare coverage criteria for the 
testing services provided have not been met. Therefore, we decided that the Plan does not have to pay for 
testing services provided on December 28, 2022, billed with codes 29819-AS-RT and 29826 AS-RT.
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 November 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates these tests are included in the dialysis rate. 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 
November 21, 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 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. 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 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on February 17, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not separately payable. 
 
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 code J3490 is not supported in the medical record. Specifically, this service is included in the 
global surgery package of codes 64483 and 64484 which were billed on the same date of service. Based on this 
information, we decided that Medicare rules for coverage of procedure code J3490 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code J3490 provided on February 17, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99233 and 99291 provided from November 
24, 2022, to November 30, 2022. 
 
You asked the Plan to pay for procedure codes 99233 and 99291. You say that the medical records support the 
billing of codes 99233 and 99291.  The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 99233 and 99291.  
 
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 99233 is Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high 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 patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. The definition of code 99291 is Critical care, 
evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 
 
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 99233 and 99291. Our reviewer says that 
the medical records do not support the billing of codes 99233 and 99291.  Our reviewer found for procedure 
code 99233 provided on November 30, 2022: The medical records did not support a detailed interval history, a 
detailed examination, and medical decision making of high complexity. For procedure code 99291 provided on 
November 25, 26, 27, 28, and 29, 2022: medical records do not support the billing of code 99291 provided on 
November 25, 2022. The medical records do not support the billing of code 99291 provided on November 26, 
2022. The medical records do not support the billing of code 99291 provided on November 27, 2022. The 
medical records do not support the billing of code 99291 provided on November 28, 2022. The medical records 
do not support the billing of code 99291 provided on November 29, 2022. 
 
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 99233 and 99291 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99233 and 99291 provided from November 24, 2022, to 
November 30, 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 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these tests are included in the dialysis rate. 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 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (62323). 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for a repeat 
epidural steroid injection have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat ESI may be considered medically 
reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain 
relief and/or improvement in function for at least three months. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a repeat epidural steroid injection have not been met. Specifically, the provided medical records do 
not support that the prior ESI provided sustained improvement in pain relief and/or function for at least three 
months. Therefore, we decided that the Plan does not have to pre-approve a repeat epidural steroid injection 
(62323).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on January 17, 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 Current Procedural Terminology (CPT 99152) remains 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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
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 documentation submitted did 
not indicate the presence of an independent trained observer during the procedure for the billed services.  In 
addition, there were no anesthesiology records documenting intra-operative/intra-procedural monitoring of this 
patient's level of consciousness and physiological status (including blood pressure, heart rate, respiratory rate, 
electrocardiogram, oxygen saturation) or medications administered. The review has determined that the use of 
CPT 99152 is not supported by the records provided.  
 
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 moderate sedation services (procedure code 99152) rendered on January 17, 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 January 13, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates these tests should be included in the dialysis rate. 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 January 
13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbo-sacral orthosis (L0635) provided on January 25, 
2023. 
 
You asked the Plan to pay for the orthosis. You say that you want to appeal this denial. The Plan denied your 
request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
lumbo-sacral orthosis (L0635) provided on January 25, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from July 22, 2022, to 
August 19, 2022. 
 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 22, 2022. The NOA was not received by the Plan. As more than 30 
days passed between the timely filing date and the NOA receipt, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for the home health services rendered from July 22, 
2022, to August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services (90999, A4657, J2501) provided on January 
2, 2021 to January 29, 2021. 
 
You asked the Plan to pay for the dialysis services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 90999, A4657, & J2501 is not supported in the medical record. Specifically, the claim 
was not billed with required value codes. Based on this information, we decided that Medicare rules for 
coverage of the dialysis services have not been met. Therefore, we decided that the Plan does not have to pay 
for dialysis services (90999, A4657, J2501) provided on January 2, 2021 to January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on December 16, 2022. 
 
You asked the Plan to pay for procedure code J3490. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is not separately payable. 
 
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 code J3490 is not supported in the medical record. Specifically, this code is included in the 
global surgery package of code 27096 which was billed for the same date of service. Based on this information, 
we decided that Medicare rules for coverage of procedure code J3490 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code J3490 provided on December 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a ventilator provided on January 17, 2023. 
 
You asked the Plan to pay for the ventilator. You say that you were told that this machine had already been 
accepted by the insurance company as medically necessary. The Plan denied your request. The Plan says this 
request is unable to be approved. 
 
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 pay for the ventilator. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found that the record 
indicates that the enrollee has chronic hypoxic and hypercapnic respiratory failure from chronic obstructive 
pulmonary disease. The record indicates that the enrollee was successfully treated with bilevel positive airway 
pressure (BiPAP). The provided primary source documentation does not contain sufficient detailed information 
in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine 
with average volume-assured pressure support (AVAPS) capability and failure of such a device has not been 
documented. The elements of the coverage criteria are not satisfied.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pay for a ventilator provided on January 17, 2023.
Appeal type: Practitioner Services
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 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this service was medically 
necessary. 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 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abdominoplasty. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria has not been met.  
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has had weight loss following bariatric 
surgery.  The record does not indicate the presence of complicating factors, such as inability to walk normally, 
chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, that have been present for 
at least three months and are refractory to usual standard medical therapy. The elements of the coverage criteria 
are not satisfied. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve abdominoplasty.