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

 
We decided that the Plan does not have to pay for the laboratory test (0241U) provided on December 9, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says the claim for this molecular pathology testing did 
not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
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 the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (0241U) 
provided on December 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel provided on November 7, 
2022, billed with codes 87631, 87481, 87486, 87491, 87496, 87498, 87532, 87541, 87551, 87556, 87561, 
87581, 87640, 87651, 87653 and 87798. 
 You asked the Plan to pay for the respiratory pathogen panel. You say that this test was medically necessary. 
The Plan denied your request. The Plan says this panel was not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the respiratory pathogen panel have not been met. Specifically, the records show that this was a 
single panel which was unbundled and reported with multiple codes. Therefore, we decided that the Plan does 
not have to pay for the respiratory pathogen panel provided on November 7, 2022, billed with codes 87631, 
87481, 87486, 87491, 87496, 87498, 87532, 87541, 87551, 87556, 87561, 87581, 87640, 87651, 87653 and 
87798.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing billed with code G0483 for 
December 27, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is covered when specific 
criteria 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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee's diagnosis was medication 
management of long term (current) drug therapy. The medical record sent by the provider shows a definitive 
urine drug testing (UDT) panel for multiple drug classes was performed, but does not show screening test 
results which are positive or inconsistent with prescription medications, dosing schedules, or history and 
expected results. The records do not support that the enrollee meets the criteria for the definitive drug testing. 
The services were not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing billed with code G0483 for December 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 4, 2022, to April 
2, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim was billed correctly. 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 March 4, 2022. The NOA was not received by the Plan until April 27, 
2022. 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 March 4, 2022, to April 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93312 and 93325 rendered on January 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 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 93312: 
 
Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode 
recording); including probe placement, image acquisition, interpretation and report  
CPT 93325: 
 
Doppler echocardiography color flow velocity mapping (List separately in addition to codes for 
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 medical records provided, 
document that procedure 00560 was performed on January 3, 2023. CPT 93312 has a bundled relationship with 
CPT 00560. In this case, a modifier is not allowed to unbundle the relationship because the medical records 
provided does not include sufficient documentation that 93312 was performed "separate and distinct" from 
00560, therefore this procedure cannot be verified. Additionally, CPT 93325 is an add-on code and requires a 
valid primary procedure code in order to be considered for reimbursement. In this case, the primary code 
cannot be supported, based on the medical records provided, therefore, 93325 is not eligible for reimbursement 
consideration. 
 
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 codes 93312 and 93325 rendered on January 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 26, 2022 to 
June 24, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 26, 2022 to June 
24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 20, 2022, to August 
18, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim shouldn't have been denied, but 
rather just subject to a late submission penalty. The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 20, 2022. The NOA was not received by the Plan until November 28, 
2022. 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 July 20, 2022, to August 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 You asked the Plan to pre-approve a power seat elevation system. You say that the requested item is medically 
necessary. The Plan denied your request. The Plan says that a power seat elevation system is not primarily 
medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received from a 
Licensed Professional Counselor (LPC) from September 29, 2022, to November 11, 2022. 
 
You asked the Plan to pay for the LPC services. You say that the provider did not know she was not covered by 
Medicare. You said that you have a good rapport with this provider but cannot afford to pay out of pocket. The 
Plan denied your request. The Plan says these services were provided by an ineligible provider type. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. You can find this rule at 
Centers for Medicare and Medicaid Services, MedLearn Matters Booklet for Medicare Mental Health, MLN 
1986542. 
 
These services were provided by a LPC, which is not a valid provider type for Medicare.  No payment can be 
made for outpatient mental health services provided by LPCs under the Medicare program. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LPC services have not been met. Therefore, we decided that the Plan does not have to pay for 
outpatient mental health services you received from a Licensed Professional Counselor (LPC) from September 
29, 2022, to November 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 rendered on October 14, 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 Current Procedural Terminology (CPT) code 99214-25 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 99214 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 moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
 
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 record does not support a 
separately identifiable evaluation and management. The record states that the patient presented for a follow up 
and orthovisc #3. This was a planned procedure; a separate evaluation and management was not performed. 
 
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 99214 rendered on October 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 1, 2022, to May 30, 
2022. 
 You asked the Plan to pay for the home health services. You say that the Plan has paid for other claims for later 
dates of service. 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 January 1, 2022. The NOA was not received by the Plan until January 31, 
2022. 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 May 1, 2022, to May 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99205 for date of service October 20, 2022. 
 
You asked the Plan to pay for procedure code 99205. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99205 is not supported in the medical record. Specifically, this service was provided on 
the same date of service as surgery procedure 31575. Without an appropriate modifier, this means code 99205 
is considered part of the global surgery period of procedure 31575 and is not separately payable as billed. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99205 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99205 for date of service 
October 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiopharmaceutical localization of tumor, 
inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool 
imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) 
transmission scan for anatomical review, localization and determination/detection of pathology, single area 
(78830). 
 
You asked the Plan to pre-approve SPECT/CT imaging. 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 follows Medicare rules. Medicare rules say that the single photon emission computed tomograph 
(SPECT) acquires information on the concentration of radionuclides introduced into the patient's body. 
 
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 SPECT/CT imaging. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no mention of the rationale 
for ordering the SPECT-CT in the clinical documents received. The review has determined that the enrollee 
does not meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SPECT/CT imaging have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiopharmaceutical localization of tumor, inflammatory process or distribution 
of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); 
tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for 
anatomical review, localization and determination/detection of pathology, single area (78830).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx test (0339U) provided January 23, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are asking for this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says based on Medicare guidelines, this test 
does not meet the requirements for approval  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the SelectMDx test (0339U) provided January 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 9, 2022, to 
November 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA and medical records. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from October 9, 2022, to 
November 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 28, 2022, to 
May 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required NOA 
and it was received. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 28, 2022, to May 
25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the PrismRA testing (81479) provided January 3, 2023. 
 
You asked the Plan to pay for  the genetic testing. You say that PrismRA should be considered medically 
necessary for the enrollee. The Plan denied your request. The Plan says this testing is not medically necessary 
because this test is not FDA approved.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Under Medicare guidelines, this test is not FDA approved and based 
on the diagnostic program, MolDX Technical Assessment, the PrismRA test is not an approved test. Online 
search of the FDA list of cleared or approved companion diagnostic testing does not mention this PrismRA. 
Search of the DEX Diagnostic Exchange registry for the diagnostic program MolDX Technical Assessment, 
states that this PrismRA test is not covered. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for  
the PrismRA testing (81479) provided January 3, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from December 5, 2022, 
to December 28, 2022.  
You asked the Plan to pay for physical therapy services. You say that you have correctly billed the services at 
issue. The Plan denied your request. The Plan says the services at issue have been billed without a required 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that physical therapy services are not supported. Specifically, the codes reported have been billed 
without a required modifier to distinguish the discipline of the plan of care under which the services are 
delivered. Based on this information, we decided that Medicare rules for coverage of physical therapy services 
have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided from December 5, 2022, to December 28, 2022.