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

 
We decided that the Plan does not have to pay for lab services billed with codes 36415, 80061 and 83036 for 
date of service April 6, 2023. 
 
You asked the Plan to pay for the lab services. You did not provide a specific argument in your appeal request. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 18, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services billed with codes 36415, 80061 and 
83036 for date of service April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 16, 2023, billed with 
procedure codes 99215-24-25 and 96574.  
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the level of care is not supported for code 
99215-24-25, and code 96574 was not billed with the required modifier to allow separate payment within the 
global surgery period. 
 
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 also say that many services within the 
postoperative period are considered to be included within payment for the global surgical procedure. Two 
exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -
24, and unrelated surgical procedures, which should be billed with modifier -79. 
 
In this case, the CPT Code Manual definition of code 99215-24-25 is office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 40-54 minutes of 
total time is spent on the date of the encounter. 
 
We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support code 99215-24-25. Our reviewer found that this level of care 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 practitioner services provided have not been met. In addition, code 96574 is 
within the global surgery period of code 14301 provided on March 2, 2023. We find that the service at issue 
may be unrelated to the surgical procedure; however, the required modifier to indicate this was not used. As 
such, the billing rules for these services have not been met. Therefore, we decided that the Plan does not have 
to pay for practitioner services provided on May 16, 2023, billed with procedure codes 99215-24-25 and 
96574.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on March 8, 2023. 
 
You asked the Plan to pay for the supplies. 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 for the supplies provided in this case. While a delivery 
ticket was provided for the billed date of service, it does not include a packing slip or details of the specific 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 supplies 
provided on March 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing procedures (G0482) billed for date of service 
January 12, 2023. 
 
You asked the Plan to pay for drug testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
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 G0482 is: Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, a physician order detailing 
the drug classes to be tested has not been provided. Based on this information, we decided that Medicare rules 
for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
drug testing procedures (G0482) billed for date of service January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 22, 2023. 
 
You asked the Plan to pay for the medical services. You say that the diagnoses billed are valid and these 
services were medically necessary. The Plan denied your request. The Plan says two of the billed diagnosis 
codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that R07.9 has an Excludes1 note in relation to R52. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on March 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E1007, E1012, E2311, and E2359). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that your current wheelchair does not have a seat belt, and your health aid does not want you to go 
outside to do your daily living activities because it is unsafe. The Plan denied your request. The Plan says the 
records do not show that it has been 5 years since you received your power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that replacement due to wear is not covered during the reasonable useful 
lifetime of the equipment.  
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 group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the group 3 power wheelchair and power 
wheelchair components are not medically necessary. Our physician reviewer found you are noted to be non-
ambulatory and cannot use a cane or walker for mobility. However, the mobility evaluation and clinical 
documentation is insufficient in terms of your motor strength, range of motion and level of function. It is 
unclear why you cannot operate a manual wheelchair or power scooter. Our reviewer found that it is also 
insufficient why you require a group 3 power wheelchair versus a group 2 power wheelchair. You are noted to 
have no history of skin breakdown and it is unclear why you cannot perform pressure relief. Our physician 
reviewer also found that there is insufficient documentation regarding your current power wheelchair and why 
it requires replacement and cannot be repaired. 
 
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 group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E1007, E1012, 
E2311, and E2359).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
  You asked the Plan to pre-approve a home ventilator system. You say that the enrollee has chronic respiratory 
failure and pulmonary hypertension. You say that the enrollee had a BiPAP machine and needs a noninvasive 
due to the BiPAP machine not working. The Plan denied your request. The Plan says a home ventilator is not 
medically necessary for this patient because their needs can be met with an alternative device such as a BiPAP 
device with average volume-assured pressure support (AVAPS).  
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the patient 
was previously noncompliant with ventilator therapy, and it is unclear if they have failed. The AVAPS therapy 
can be delivered with a BiPAP and is the best practice at this time. While it is unknown if compliance will be 
an issue, changing the mode of therapy due to noncompliance is no standard practice. Therefore, the patient 
does not meet the requirements or have supportive documentation for a home ventilator. 
 
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 system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary 
hypercoagulability) gene analysis, 20210G>A variant (81240). 
 
You asked the Plan to pre-approve F2 gene analysis, 20210G>A variant. You say that this testing is medically 
necessary to determine which anticoagulant is appropriate. The Plan denied your request. The Plan says this 
testing is not covered under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing for F2 and F5 genes for all risk 
factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered 
except for pregnant parties. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F2 gene analysis, 20210G>A variant have not been met. Therefore, we decided that the Plan does 
not have to pre-approve F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene 
analysis, 20210G>A variant (81240).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 1, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on March 1, 2023.
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 a fall risk and require therapy services for 
your shoulder. The Plan denied your request. The Plan says you do not meet the 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 you do not require treatment by multiple therapies. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Invitae Hereditary Transthyretin-mediated 
amyloidosis (hATTR amyloidosis) test. 
 
You asked the Plan to pre-approve the Invitae hATTR amyloidosis test. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. We find that the Invitae hATTR amyloidosis test has not been 
approved for coverage based on information in the DEX Diagnostic Exchange. Based on this information, we 
decided that Medicare rules for coverage of the Invitae hATTR amyloidosis test have not been met. Therefore, we decided that the Plan does not have to pre-approve the Invitae Hereditary Transthyretin-mediated 
amyloidosis (hATTR amyloidosis) test.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S9131 and S9123 billed for dates of service 
April 3, 2023, to April 6, 2023. 
 
You asked the Plan to pay for procedure codes S9131 and S9123. You say that you have an authorization for 
the dates of service. The Plan denied your request. The Plan says the billed codes are invalid for Medicare 
purposes.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes S9131 and S9123 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes S9131 and S9123 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes S9131 and S9123 billed for dates of service April 3, 2023, to 
April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat transforaminal epidural steroid injection 
(TFESI) (64483).  
 
You asked the Plan to pre-approve a repeat TFESI. You say that the request is medically necessary. The Plan 
denied your request. The Plan says the information submitted fails to meet medical necessity criteria. 
 
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 repeat TFESI. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found that the previous bilateral L5-S1 
transforaminal lumbar epidural steroid injection on March 28, 2023 provided 100% relief for approximately 45 
days. The review has determined that the enrollee does not meet the LCD criteria for a repeat TFESI. The 
repeat TFESI is not considered 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 the repeat TFESI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a repeat transforaminal epidural steroid injection (TFESI) (64483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient admission provided from March 25, 2023, 
to March 30, 2023. 
 
You asked the Plan to pay for the acute inpatient admission. The Plan denied your request. The Plan says based 
on the review, a separate inpatient admission is not recognized. The Plan also says that payment for these 
services was included with the reimbursement for the initial hospital stay. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 acute inpatient admission. Our physician 
reviewer found the enrollee was initially admitted to the hospital on March 6, 2023, for acute respiratory failure 
due to an aspiration with pneumonia, sepsis, and wheezing, all of which improved with treatment, but they 
continued to have a weak cough. The enrollee was discharged on March 15, 2023. Our reviewer also found that 
the computed tomography at the time showed unchanged multifocal aspiration/pneumonia involving the right 
upper and bilateral lower lobes and persistent protein calorie malnutrition on pureed diet, however, the enrollee 
has normal white blood cell count and was stable hemodynamically. The enrollee did not follow-up with their 
doctor as outpatient as planned. On March 25, 2023, the enrollee was readmitted to the hospital with aspiration 
pneumonia again with sepsis and hypoxia. The enrollee required fluids, intravenous antibiotics, oxygen 
support, and steroids. The readmission was medically necessary according to the provided documentation. Our 
physician reviewer found that based on the stability of the enrollee clinically, at baseline on the first admission 
discharge date, the enrollee's readmission did not result from a premature discharge from the hospital. 
 
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 acute inpatient admission have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient admission provided from March 25, 2023, to March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99140 and 99100 billed for date of service 
May 8, 2023. 
 
You asked the Plan to pay for procedure codes 99140 and 99100. You say that the timely filing requirement for 
this claim should be waived. The Plan denied your request. The Plan says procedure codes 99140 and 99100 
are considered bundled and 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 procedure code. 
 
We find that procedure codes 99140 and 99100 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99140 and 99100 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99140 and 99100 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99140 and 99100 billed for date of service 
May 8, 2023.