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

 
We decided that the Plan has to pay for the Guardant360CDx testing (81479) provided on November 11, 2022. 
 
You asked the Plan to pay for the services. You say that the services are covered. The Plan denied your request. 
The Plan says that the provider did not bill as required by Medicare coding regulations. 
 
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 file shows that the claim has a DEX-Z code. Further investigation 
shows that the testing is covered. Therefore, we decided that the Plan has to pay for the Guardant360CDx 
testing (81479) provided on November 11, 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 genetic testing provided on September 13, 2022, billed 
with codes 81292, 81295, 81298, 81317, 81351, 81406, 81407, 81408, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 13, 2022, billed with codes 81292, 81295, 81298, 81317, 81351, 81406, 81407, 81408, and 81479.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat bariatric surgery. 
 
You asked the Plan to pre-approve a repeat bariatric surgery. You say that the requested repeat bariatric surgery 
is medically necessary. The Plan denied your request. The Plan says under Medicare guidelines, your request is 
not medically necessary because your records show the enrollee already had another bariatric surgical 
procedure and have been losing weight and doing well. The care team describes the enrollee as continuing to 
lose weight and do well. The records do not show the need to replace a defective device or need to correct a 
complication from the previous surgeries. 
 
The Plan follows Medicare rules. Medicare rules say that repeat bariatric surgery is generally not reasonable 
and necessary. Medicare does not provide prior authorization for these services.  
 
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 repeat bariatric surgery. Our reviewer says that the requested repeat bariatric surgery is not considered medically necessary. Our physician reviewer 
found that the male enrollee has a history of obesity, diabetes, and hypertension. The record sent by the 
provider indicates the enrollee already had other bariatric surgery in the past for treatment of obesity. The 
enrollee had a sleeve gastrectomy surgery in 2019. The enrollees BMI on April 25, 2023 was 48.09. Notes 
from the bariatric physician state that day that the enrollee "lost 78 pounds since surgery and gained 2 pounds 
(lbs.) since last visit on 4/5." Notes from the April 5, 2023 visit states "Patient is doing well overall. Patient is 
eating a solid food diet without any problems. Patient denies any nausea, vomit or GERD symptoms. Since last 
the visit he has stopped eating starches. Has started Ozempic March 9, 2023. Doing well." At that visit the 
enrollee had "lost 7 lbs. since last visit on March 8, 2023." There is no evidence that the enrollee is having 
complications related to the prior surgery. There is no clinical rationale for repeat bariatric surgery. The review 
has determined that the repeat bariatric surgery 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 a repeat bariatric surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a repeat bariatric surgery.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services rendered on January 20, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the place of service must match the procedure code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that these services are not supported in the medical record. Specifically, place of service 21 - inpatient hospital - would be inappropriate for emergency services. The correct place of service is 23. 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 emergency room services rendered on January 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services with diagnosis codes A40.8 and 
N17.0 rendered from October 9, 2022, to October 17, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration of the DRG adjustment. The Plan denied your request. 
The Plan says a post-service, post-payment clinical validation audit was performed to help ensure that the 
diagnosis codes on the claim were supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that SOFA criteria are the international standard for sepsis. SIRS is not specific for sepsis and identifies 
infection and other inflammatory conditions. The creatinine was only shown to be elevated for 6 hrs during the 
initial phase of the illness and on 10/12/22 - a little over 72 hours after presentation - was normal. There is no 
creatinine level between 0500 on 10/10/22 and 15:11 on 10/12/22.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services with diagnosis codes A40.8 and N17.0 rendered from October 9, 2022, to 
October 17, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on December 31, 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 the downcode from CPT 99285 to CPT 99284 is upheld. 
 
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. 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 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 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 documented history is not 
comprehensive. The medical decision making was not of high complexity. As such, the billing of CPT 99285 is 
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 emergency room services (procedure code 99285) rendered on December 31, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency medicine services provided on February 15, 2023.  
 
You asked the Plan to pay for the emergency services. You say that these should both be paid. The Plan denied 
your request. The Plan says that because these two visits were not for unrelated problems, only one of the 
physicians can be paid for this 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. We find that the Plan is misinterpreting the rules in regard to payment of two 
emergency room visits provided on the same date. While the rules do normally indicate that two physicians in 
the same group with the same specialty cannot bill separately for the service, there are exceptions. In this case, 
the two emergency medicine physicians saw the enrollee in different facilities. The provider at issue in this 
case saw the enrollee and he was then sent to the second facility and was seen by an emergency physician 
there. These two visits are clearly distinct and would not be reported only once.  Therefore, we decided that the 
Plan has to pay for the emergency medicine services provided on February 15, 2023.   
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services rendered on March 3, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the diagnosis codes associated to this claim should not be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
R26.9 and R27.0 should not be reported together, per the Excludes1 Notes guidelines. 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 therapeutic services rendered on March 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes 88377 and G0452) 
rendered on January 25, 2023. 
 
You asked the Plan to pay for the services. You say that you submitted medical records for review. The Plan 
denied your request. The Plan says 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 the denied codes is: 
 
CPT 88377: 
 
Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure 
 
Healthcare Common Procedure Coding System (HCPCS) G0452): 
 
Molecular pathology procedure; physician interpretation and report 
 
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 records do not support using 
CPT 88377 separately from CPT 81342. CPT 88377 is included in CPT 81342. The medical records also do 
not support G0452 as being separate and distinct from the inclusive procedure code CPT 81342. The denied 
codes 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure codes 88377 and G0452) rendered on January 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty services. 
 
You asked the Plan to pre-approve kyphoplasty services. You say that the records provided support the need 
for the service in dispute. The Plan denied your request. The Plan says the medical necessity criteria are not 
met because the enrollee's pain is multifactorial with multilevel disc disease in the lower thoracic spine.  
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty procedures will be considered medically 
reasonable and necessary for painful, debilitating, osteoporotic vertebral collapse/compression fractures, 
defined as those that have not responded to non-surgical medical management with and without methods of 
immobility. 
 
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 kyphoplasty services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found there is no trial of bracing 
for fracture. More conservative measures are needed.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve kyphoplasty services.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the foot/toe strapping coded as 29550. We decided that the Plan does 
not have to pay for the EM services.  
 
You asked the Plan to pay for the evaluation and management (EM) services coded as 99213 and the foot/toe 
strapping coded as 29550 provided on January 26, 2023. You say that it is felt that these services should be 
covered.  The Plan says that code 99213 cannot be paid as it was reported with diagnosis codes that cannot be 
reported together. In addition, code 29550 cannot be paid because an anatomical modifier was not used to 
indicate what side the procedure was performed on.  
 
We decided that the Plan has to pay for the foot/toe strapping coded as 29550.  
 
The Plan follows Medicare rules. Medicare rules say that for codes with bilateral indicators of 1, it is 
recommended to use an anatomical modifier for unilateral procedures only when needed to show that 
additional services are not duplicates.  
 
In this case, the code 29550 was reported with diagnosis code M71.571, which refers to bursitis of the right 
ankle and foot. There is no other code billed on the claim to which this procedure could be considered 
duplicate. As such, there is no need to report modifier -RT for this code. Therefore, we decided that the Plan 
has to pay for the foot/toe strapping coded as 29550.  
 
We also decided that the Plan does not have to pay for the EM services. 
 
"The Plan follows Medicare rules. Medicare rules say that providers must comply with ICD-10-CM guidelines. 
These guidelines state that, in most cases, if a diagnosis code has an Excludes1 note related to another 
diagnosis code, those codes cannot be reported together. 
 
Code 99213 was reported with diagnosis codes M71.571 and M20.12. The base code of M71 has an Excludes1 
note for diagnosis code M20.1, for bunion/hallux valgus. As such, these two codes should not be reported 
together. Therefore, we decided that the Plan does not have to pay for the EM services. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the records provided support the need for a 
home ventilator.  The Plan denied your request. The Plan says the records show the requested device will be 
used to provide treatment that uses air pressure through a mask to keep your airways open and will be used in a 
bi-level positive airway pressure (BiPAP) mode.  
 
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 criteria for coverage have not been met. Our physician reviewer found the records document that the 
home ventilator is being requested for use in a volume assured pressure support mode which is a modality 
which could be provided by a bilevel positive airway pressure (BiPAP) device with average volume assured 
pressure support (AVAPS) and a back-up rate. Provided records do not document trial and failure of a BiPAP 
device with AVAPS and a back-up rate. Ventilators used to provide continuous positive airway pressure 
(CPAP) or bi-level CPAP therapy for chronic respiratory failure consequent to chronic obstructive pulmonary 
disease are not reasonable and necessary. The provided records in this case do not provide adequate detailed 
information to meet Medicare criteria for coverage of a ventilator as opposed to a BiPAP device with AVAPS 
and a back-up rate. 
 
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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging provided on January 06, 2023, by an out-of-network 
(OON) provider.  
 
 You asked the Plan to pay for imaging. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for imaging provided on January 06, 2023, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thyroid oncology laboratory testing provided on  
January 30, 2023. 
 
You asked the Plan to pay for the thyroid oncology laboratory testing. You say that thyroid oncology 
laboratory testing was medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the lab testing (ThyroSeq) does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that thyroid oncology laboratory testing is covered when 
the criteria listed in the Medicare rules section of this decision are met.  
 
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 thyroid oncology laboratory testing. Our 
reviewer says that the requested thyroid oncology laboratory testing is not considered medically necessary. Our 
physician reviewer found that given that your FNA demonstrated thyroid nodule to be Bethesda category V, 
suspicious for malignancy, it does not meet the Medicare LCD #2 criteria above.  
 
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 thyroid oncology laboratory testing have not been met. Therefore, we 
decided that the Plan does not have to pay for thyroid oncology laboratory testing provided on  
January 30, 2023.