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

 
We decided that the Plan does not have to pay for the drug test (80307) and the drug test, 15-21 drug class(es) 
(G0482) provided on December 28, 2022.  
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The service for code 80307 is redundant and has been performed by the same and/or different provider on the 
same date of service. Additional reimbursement is not warranted. Medicare does not pay for duplicate testing. 
NCCI Policy Manual states, "Beginning January 1, 2017, presumptive drug testing may be reported with CPT 
codes 80305-80307. These codes differ based on the level of complexity of the testing methodology. Only one 
code from this code range may be reported per date of service." Per claims history, code 80305 was paid on for 
date of service December 28, 2022. Therefore, code 80307 will not be reimbursed. Furthermore, code G0482 
for 15-21 drug classes was billed; however, the laboratory results submitted support code G0483 for 22 or more 
drug classes, as 23 drug classes were tested. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug test (80307) and the drug test, 15-21 drug class(es) (G0482) provided on December 28, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for destruction of lesions (procedure code 17000 and 17003) rendered on 
December 7, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for and reconsidered. The Plan 
denied your request. The Plan says that that the lesions were documented as having a benign appearance and 
there is no documentation of bleeding, persistent or intense itching, pain, or any of the other criteria 
established. 
 
The Plan must follow Medicare rules. Medicare rules say that removal of lesions is covered if there is clinical 
uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on 
lesional appearance, such as increased rate of growth and/or color changes. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the term "pre-malignant" was used to describe the skin lesions. The enrollee has a covered indication 
for these services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
destruction of lesions (procedure code 17000 and 17003) 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pre-approve Feraheme. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no clinical rationale for Feraheme 
therapy. The review has determined that the documentation does not support that the Feraheme is medically 
reasonable or necessary or safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intrathecal pain pump services to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve intrathecal pain pump services. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for OON 
services have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
intrathecal pain pump services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 95937, 95938 and 95939. 
We decided that the Plan does not have to pay for the services described by procedure code(s) G0453.  
 
You asked the Plan to pay for medical services (G0453, 95937, 95938 and 95939) provided on March 15, 
2023. You say that these services were necessary and are supported in the medical record. The Plan says that it 
is inappropriate to use modifier 26 with code G0453. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 95937, 95938 and 
95939.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 95937, 95938 and 95939.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
G0453. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that modifiers 26 and TC cannot 
be used with codes that have a PC/TC indicator of 0. 
 
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 described by procedure code(s) G0453 have not been met. 
Specifically, code G0453 has a PC/TC indicator of 0, meaning that modifiers 26 and TC cannot be used with 
this code. However, this claim was submitted with modifier 26 appended to code G0453. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code(s) G0453. 
 
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 BostonGene Tumor Portrait Panel (81455) provided on 
December 19, 2022. 
 
You asked the Plan to pay for the BostonGene Tumor Portrait Panel. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says this testing is not covered because the record does not 
show that the enrollee is seeking further cancer treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS testing is covered when the enrollee has 
recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer 
 
We looked at the file and Medicare rules. In this case the record does not show that the enrollee has recurrent, 
relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, we decided that 
Medicare rules for coverage of the BostonGene Tumor Portrait Panel have not been met. Therefore, we decided 
that the Plan does not have to pay for the BostonGene Tumor Portrait Panel (81455) provided on December 19, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet the 
guidelines for care in an LTACH.  
 
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 the enrollee is receiving appropriate care in the current acute care setting as provided 
by the Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospitalist visit provided on December 5, 2022. 
 
You asked the Plan to pay for hospitalist visit. You say that this was billed with valid and payable diagnosis 
codes. The Plan denied your request. The Plan says there is an Excludes1 note between diagnosis codes G30.9 
and F03.90 so these codes should not be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of G30.9 and F03.90. Diagnosis code F03.90 is an Excludes1 
code under code G30.9, so these two diagnoses cannot be billed together. Therefore, we decided that the Plan 
does not have to pay for a hospitalist visit provided on December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93306 rendered on April 11, 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) code 93306 (1 unit) 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 93306 is "Echocardiography, transthoracic, real-time 
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral 
Doppler echocardiography, and with color flow Doppler echocardiography." 
 
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 submitted records show multiple images from transthoracic echocardiogram done on 4/11/23. There is no report. Only static images are 
in the records. Absent a report and description of technique, reimbursement will not be possible. 
 
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 procedure code 93306 rendered on April 11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan, thorax, low dose for lung cancer screening, 
without contrast material(s) (71271) provided on February 9, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says lung cancer screening is not allowed when billed without a covered diagnosis supporting 
the lung cancer screening. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the CT scan have not been met. CPT code 71271 was billed with diagnoses code Z12.2 (Encounter for screening for malignant neoplasm of respiratory organs) which is not an 
acceptable diagnosis code as diagnosis does not indicate the enrollee is or was a smoker. Therefore, we decided 
that the Plan does not have to pay for the CT scan, thorax, low dose for lung cancer screening, without contrast 
material(s) (71271) provided on February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77300 billed for date of service May 5, 2023.  
 You asked the Plan to pay for procedure code 77300. You say that this service was medically necessary. 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 77300 is 10. The MAI value for this code is 3. You billed 18 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 77300 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 77300 billed for date of service May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 18, 2023. 
 
You asked the Plan to pay for the office visit. You say that this service has been paid for in the past. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit provided 
on January 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implantable CardioMEMS device (C2624) provided on 
September 21, 2022. 
 
You asked the Plan to pay for the device. You say that you are appealing the denial with supporting medical 
records. The Plan denied your request. The Plan says this device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there remains a lack of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, the CardioMEMS system 
would not be considered medically appropriate and necessary in the enrollees clinical management. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pay for the implantable CardioMEMS device (C2624) provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve an office visit. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not authorized. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has complex medical and 
respiratory needs that can be met at a long term acute level of care. The Plan denied your request. The Plan 
says criteria for admission to the LTACH have not been met.  
 
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 the enrollee appears unable to wean at this time and requires additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. There 
are no services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to the LTACH would not be clinically advantageous at this time and completion of treatment 
at the current facility is recommended.  
 
 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuroplasty,glucose, blood by glucose monitoring device and 
injections provided on October 20, 2022. 
 
You asked the Plan to pay for neuroplasty,glucose, blood by glucose monitoring device and injections. You say 
that the services were medically necessary. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for neuroplasty,glucose, 
blood by glucose monitoring device and injections provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the psychotherapy services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve a consultation. You say that you would like to see a specialist. The Plan 
denied your request. The Plan says an authorization was approved with an in-network provider for a second 
opinion. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the psychotherapy services to be provided by an OON provider.