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

 
We decided that the Plan has to pay for drug testing services provided on October 10, 2022. 
 
You asked the Plan to pay for the drug testing services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that the denial is upheld because no records were provided by the 
referring provider. 
 
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's sole rationale for denial is that they do not have medical 
records from the referring provider.  However, this is not true.  The case file contains clear medical records that 
were electronically signed by the referring practitioner who ordered these labs.  It is not clear why the Plan did 
not see these as they were in the file.  The Plan has offered up no other rationale for denial.  The burden is on 
the Plan to show that its denial is correct.  By failing to address the medical records from the referring provider 
that are in the file, we find that the Plan has not met this burden. Therefore, we decided that the Plan has to pay 
for drug testing services provided on October 10, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99214) rendered on 
December 6, 2022. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says the documentation does not support the level of service provided to the enrollee. 
 
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 visit. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the provided medical records do not 
document 2 out of 3 of multiple diagnoses or management options, a moderate amount and complexity of data 
reviewed and moderate risk of complication. Additionally, the records do not clearly document 30-39 minutes 
of total time was spent on the date of the encounter. 
 
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 visit have not been met. Therefore, we decided that the Plan does not have 
to pay for an office visit (procedure code 99214) rendered on December 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on November 17, 2022. 
 You asked the Plan to pay for the home health services. You say that this bill type is correct. The Plan denied 
your request. The Plan says the NOA was not received. 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, you have not submitted the required NOA.  As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided on November 17, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 88342-59 and 88341-59 billed for date of service 
August 22, 2022. 
 
You asked the Plan to pay for codes 88342-59 and 88341-59. You say that these were distinct tests provided 
and should be paid. The Plan denied your request. The Plan says code 88342-59 is not supported by the 
medical record. This code is included in codes 88189 and 88184 (which have been paid), so it cannot be 
separately reimbursed. The documents do not support that this procedure is distinct or independent from other 
services performed, so the 50 modifier is not supported. For code 88341-59, that code is not covered because 
the primary service code (88342) is not covered. Code 88369-59 has been overturned and is not in dispute. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
 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 codes 88342-59 and 88341-59 Our reviewer 
says that the use of the 59 modifier to allow for separate payment of codes 88342-59 and 88341-59 is not 
supported by the medical records. Our physician reviewer found the laboratory report does not include 
documentation to support that code 88342 is a distinct separate procedure from code 88184 and CPT 
88189.  Per Medicare rules "Immunocytochemistry (e.g., CPT codes 88342, 88341, 88344, 88360, 88361) and 
flow cytometry (e.g., CPT codes 88184-88189) should generally not be reported for the same or similar 
specimens. The diagnosis should be established using one of these methods.".  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 88342-59 and 88341-59 have not been met. Therefore, we decided that 
the Plan does not have to pay for codes 88342-59 and 88341-59 billed for date of service August 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator you purchased on September 8, 
2022. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you purchased travel oxygen since you 
can't take larger tanks with you. You stated that this item is what you needed to use for sleeping. The Plan 
denied your request. The Plan says purchased oxygen equipment is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. 
 
In this case, you purchased the oxygen concentrator in question.  Neither Medicare nor your Plan covers 
oxygen equipment that is purchased instead of rented. Therefore, we decided that the Plan does not have to pay 
for the oxygen concentrator you purchased on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 99153 billed for date of service October 
27, 2022. 
 
You asked the Plan to pay for procedure code(s) 99153. You say that you supplied medical records to support 
payment. The Plan denied your request. The Plan says this code is included in the facility payment and is not 
separately payable.   
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components are payable when the enrollee is not a patient of any hospital, and the service is received 
in a setting that is not part of a hospital. 
 
The Plan has not submitted evidence that indicates this service was provided to the enrollee while an inpatient 
or outpatient in any hospital. In this case, CPT code 99153 does not need to be billed with a modifier to 
indicate the professional component only. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99153 have been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 99153 billed for date of service October 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
17, 2022.  
 You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. 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 claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 17, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 4, 2023. 
 
You asked the Plan to pay for the medical services. You say that this claim was coded appropriately. The Plan 
denied your request. The Plan says you billed this claim with an inappropriate pair of diagnoses. 
 
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 E79.0 and M10.071. Code M10.071 is an Excludes1 code 
under code E79.0, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on February 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service November 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. 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 lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed for date of service 
November 17, 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 the enrollee requires the level of additional care 
provided at an IRF. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
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 that you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 13, 2023. 
 
You asked the Plan to pay for the medical services. You say that you believe the diagnosis codes are valid. The 
Plan denied your request. The Plan says you billed these services with an inappropriate pair of diagnoses. 
 
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 S33.6XXA and M51.36. Code M51.36 is an Excludes1 
code under code S33.6XXA, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on January 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
December 21, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that these services were reported 
correctly and should be paid.  The Plan denied your request. The Plan says these services are not supported for 
separate billing. 
 
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 state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 87481 is a column II code to column I code 87801. This code has not 
been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. 
 
We have also confirmed that code 87653 is a column II code to column I code 87801; however, 87653 was 
billed with a -59 modifier.  
 
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 procedure code 87653. Our reviewer says that the criteria for 
coverage have not been met.  Our reviewer found that the laboratory report does not include documentation to 
support the modifier, or to show that the service was unusual and non-overlapping. The services represented by 
code 87801 includes multiple organisms.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481 and 87653 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service December 21, 
2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided by a Licensed 
Marriage and Family Therapist (LMFT) from December 8, 2022, to December 22, 2022. 
 
You asked the Plan to pay for the LMFT services. You say that this provider treats you for extreme anxiety and 
depression. The Plan denied your request. The Plan says you saw a provider that is not a Medicare-qualified 
provider, so these services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that rules state 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. 
 
In this case, the provider that you saw is a LMFT, which is not a covered provider type for Medicare. 
Therefore, the services you received from this provider cannot be covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the LMFT services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided by a Licensed Marriage and Family Therapist (LMFT) from 
December 8, 2022, to December 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88342 and 88341 billed for date of service 
August 29, 2022. 
 You asked the Plan to pay for procedure code 88342 and 88341. You say that these services are separately 
payable. The Plan denied your request. The Plan says payment for code 88342 and 88341 is bundled into 
payment for code 88361. 
 
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 
88342 and 88341 are column II codes to column I code 88361. This claim has not been billed with an 
appropriate modifier to bypass the edit. Although you claim that you billed a modifier, the only modifier on the 
claim is 26.  The 26 modifier does not affect the bundling of these codes. 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 88342 and 88341 billed for date of service August 29, 2022.
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 the enrollee's admission to an LTACH is 
medically necessary. The Plan denied your request. The Plan says the enrollee is unstable to transfer to an 
LTACH. Continued stay at the acute hospital until the enrollee is stable enough for discharge to a lower level 
of care has not been denied. 
 
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 at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 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 the Guardant Reveal testing provided on October 23, 2022. 
 
You asked the Plan to pay for the Guardant Reveal testing. You say that this is a covered test to check for 
residual disease after curative surgical treatment. The Plan denied your request. The Plan says this is 
considered experimental at this time. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is only covered for certain indication.  
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 Guardant Reveal testing. Our reviewer 
says that the Guardant Reveat testing provided does not meet Medicare coverage criteria for this patient. Our 
physician reviewer found the enrollee has had the surgery and adjuvant chemotherapy.  Current coverage of 
Medicare is for those who undergo surgery within 3 months to determine whether adjuvant chemotherapy may 
be helpful.  There are insufficient data to support ctDNA testing to detect recurrence after the surgery and the 
adjuvant chemo.  The National Comprehensive Cancer Network guidelines state that there are currently 
insufficient data to recommend the use of post-surgical ctDNA to estimate risks of recurrence. 
 
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 Guardant Reveal testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Guardant Reveal testing provided on October 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20930 billed for date of service March 17, 
2022. 
 
You asked the Plan to pay for procedure code 20930. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 20930 is 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 code 20930 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 20930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 20930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 20930 billed for date of service March 17, 2022.