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

 
We decided that the Plan does not have to pay for procedure codes 87801, 87150, 87481, 87500, 87641, 87653, 
and 87798 billed for February 7, 2023. 
 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 services are not covered. 
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, there is no documentation or 
identification for the test(s) performed. Based on this information, we decided that Medicare rules for coverage 
of these services 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, we have confirmed that codes 
87150, 87481, 87500, 87641, 87653, and 87798 are column II codes to column I code 87801. This claim has 
not been billed with an appropriate modifier to bypass the edit. The -XU modifiers are not supported as a 
separate and distinct procedural service. Based on the claim submitted, Medicare billing criteria have not been 
met. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 87801, 87150, 87481, 87500, 
87641, 87653, and 87798 billed for February 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 22, 2022, to May 
21, 2022. 
 You asked the Plan to pay for the home health services. You say that although you submitted the NOA after the 
final claim, these services were medically necessary. 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 February 21, 2022. The NOA was not received by the Plan until February 
6, 2023. 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 home health services provided 
from April 22, 2022, to May 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Triiodothyronine T3 testing (84481) provided on June 8, 
2022. 
 
You asked the Plan to pay for Triiodothyronine T3 testing. You say that this is supported in the records. The 
Plan denied your request. The Plan says there is not an order for this test. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules also state that all diagnostic X-Ray tests, diagnostic laboratory tests, 
and other diagnostic tests must be ordered by the physician who is treating the beneficiary and tests not ordered 
by the physician who is treating the beneficiary are not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Triiodothyronine T3 testing have been 
met. The submitted records do not include an order for this specific test. Therefore, we decided that the Plan 
does not have to pay for Triiodothyronine T3 testing (84481) provided on June 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the 
brain. 
 
You asked the Plan to pre-approve the PET scan. You say that you are requesting reconsideration for the denial 
of a PET scan. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the enrollee does not meet diagnostic 
criteria for frontotemporal dementia. The enrollee was given a diagnosis of Alzheimer's disease based on a 
clinical basis. Therefore, the base requirement for coverage has not been met in this case and would not be 
eligible for coverage.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service April 20, 
2023.   
You asked the Plan to pay for procedure code 99284. You say that 99284 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 99284 is 1. The MAI value for this code is 3. You billed 2 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 99284 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99284 billed for date of service April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 23, 2022, billed 
with procedure code 01953-50. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says code 01953 was billed with an inappropriate 
anesthesia modifier.  
The Plan must follow Medicare rules. Medicare rules say that physicians bill for the anesthesia services 
associated with multiple bilateral surgeries by reporting the anesthesia procedure with the highest base unit 
value with the multiple procedure modifier -51.  
 
We looked at 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. This claim has not been billed with an 
appropriate anesthesia modifier. Therefore, we decided that the Plan does not have to pay for practitioner 
services provided on November 23, 2022, billed with procedure code 01953-50.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 19, 2023, billed with 
codes 81209, 81216, 81223, 81241, 81238, 81242, 81250, 81249, 81279, 81339, 81298, 81305, 81311, 81307, 
81320, 81317, 81321, 81334 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. 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 
January 19, 2023, billed with codes 81209, 81216, 81223, 81241, 81238, 81242, 81250, 81249, 81279, 81339, 
81298, 81305, 81311, 81307, 81320, 81317, 81321, 81334 and 81345.
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 an LTACH level of care is recommended 
for complex medical management with an interdisciplinary treatment team approach. The Plan denied your 
request. The Plan says the request for LTACH placement does not meet medical necessity criteria. 
 
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 not medically stable for transfer. The enrollee does not require 
services at the LTACH that are not available at the acute care hospital where they are currently receiving care. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan.  
 
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: 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 exceeds the criteria for an 
appropriate LTACH admission. The Plan denied your request. The Plan says based on Medicare guidelines, the 
LTACH services requested do not meet the requirements for approval. 
 
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 has ongoing acute medical issues and still requires acute care 
services. The enrollee continues to receive acute care services and these have not been denied. The medical 
record does not indicate that the enrollee requires services that they are not currently receiving but that would 
be available at the LTACH facility.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service March 17, 
2023. 
 
You asked the Plan to pay for procedure code 99284. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says the service at issue 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 many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. However, evaluation and 
management services may be paid separately when reported with modifier -25.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 69210 
provided on March 17, 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 procedure code 99284 billed for 
date of service March 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch block (MBB) procedures (64490, 64491). 
 
You asked the Plan to pre-approve MBBs. You say that MBBs are a necessity for your care. The Plan denied 
your request. The Plan says MBBs are 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 pre-approve MBBs. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is only weak evidence to support diagnostic and therapeutic thoracic (mid-back) MBBs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MBBs have not been met. Therefore, we decided that the Plan does not have to 
pre-approve medial branch block (MBB) procedures (64490, 64491).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service December 14, 2021. 
 
You asked the Plan to pay for code 99285. You say that this claim was not paid as billed. The Plan denied your 
request. The Plan says code 99285 is not supported by the medical record. The patient's presenting problem 
was not a high/immediate threat to lift, so this code was down-coded to 99284. 
 
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: An expanded problem focused history; 
An expanded problem focused examination; and Medical decision making of moderate complexity. 
 
 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the patient was a 95-year-old male who presented to the 
emergency room with nausea. The documentation supports an expanded exam, but not an expanded problem-
focused history or medical decision making of at least moderate complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service December 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound supplies provided on March 25, 2022. 
 
You asked the Plan to pay for the wound supplies. You say that you had staffing issues that prevented you from 
submitting this claim. The Plan denied your request. The Plan says you did not timely file your claim. The Plan 
follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be 
filed no later than one calendar year after the date of service. The record shows that a claim for the wound 
supplies was not filed until May 11, 2023. This means that more than one calendar year from the date of 
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for 
wound supplies provided on March 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker you purchased on February 28, 2023. 
 
You asked the Plan to pay for the walker. You say that your local surgical supply store didn't have the right 
type of walker, so you ordered it online. The Plan denied your request. The Plan says you purchased this item 
from a vendor that is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider from 
whom you purchased the walker at issue is not enrolled in the Medicare program. Therefore, we decided that 
the Plan does not have to pay for the walker you purchased on February 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. You also say the enrollee's provider does not feel they can tolerate 3 hours of daily therapy. The 
Plan denied your request. The Plan says admission to an LTACH is not medically necessary.  
 
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 that the acute hospital can provide for all the enrollees present inpatient care needs 
and the Plan has not stated that continued care in the short-term acute hospital will not be covered. The enrollee 
is presently receiving appropriate services in the acute care setting, and the records do not support the need to transfer from one acute hospital to another. Continued care in the short-term acute hospital is appropriate until 
the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute 
rehabilitation facility, or a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent testing (87633, 87634, 87798) billed for 
date of service December 20, 2022. 
 
You asked the Plan to pay for infectious-agent testing. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the claim for the molecular pathology testing denoted by 
procedure code 87633 did not include the required unique identifier. The Plan also says that the number of 
units billed for codes 87634 and 87798 exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test denoted 
by code 87633, the MolDX program requires these tests to be reviewed to determine whether Medicare 
reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique 
identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of procedure code 87633 
have not been met. 
 
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 87634 is 1. The MUE for CPT code 87798 is 13. The MAI value for these 
codes is 3. You billed 2 units of code 87634 and 14 units of code 87798, exceeding the MUE for each code. 
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 codes 87634 and 87798 have not been met. 
 
Therefore, we decided that the Plan does not have to pay for infectious-agent testing (87633, 87634, 87798) 
billed for date of service December 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines 
for services in an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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.