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

 
We decided that the Plan does not have to pay for the genetic testing coded as 81225, 81226, 81227, 81230, 
81231, 81240, 81241, 81291,81328, 81355, 81401 and 81479 provided September 9, 2022. 
 You asked the Plan to pay for the genetic testing. You say that please find the attached documents, review and 
reconsider the claim for payment. The Plan denied your request. The Plan says the information needed to 
consider this charge is required. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found although genome-wide association studies report inter-individual variability, high-quality, 
randomized controlled trial data demonstrating improved clinical outcomes are lacking. Many early phase 
clinical trials are exploratory, with no formal genomic hypothesis, and have small sample sizes that make it 
difficult to identify important gene variants influencing pharmacokinetics and pharmacodynamics (Lesko and 
Schmidt, 2014). However, clinical utility has been established for pharmacogenetic testing for a number of 
gene biomarkers and their specific drug targets. The review has determined that there was no specific clinical 
rationale for the obtained laboratory studies on September 9, 2022. The items/services at issue in this case were 
not 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing coded as 81225, 81226, 81227, 81230, 81231, 81240, 81241, 
81291,81328, 81355, 81401 and 81479 provided September 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve the Minuteman procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says this service is considered experimental. 
 
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 the Minuteman procedure. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is considered experimental. 
 
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 Minuteman procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endovascular ablation therapy of incompetent extremity 
veins (code 36482) provided on June 28, 2022. 
 
You asked the Plan to pay for endovascular ablation therapy of incompetent extremity veins. You say that 
endovascular ablation therapy of incompetent extremity veins was medically necessary. The Plan denied your 
request. The Plan says endovascular ablation therapy of incompetent extremity veins is not covered. 
 
The Plan follows Medicare rules.  
 
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 endovascular ablation therapy of 
incompetent extremity veins. Our reviewer says that endovascular ablation therapy of incompetent extremity 
veins is not considered medically necessary in this case. Our physician reviewer found that based on the 
medical records provided there is no documentation that the VenaSeal procedure (Endovascular Ablation 
Therapy of Incompetent Extremity Veins) at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for the enrollee. The provided records in this case do not clearly document the failure 
of an adequate (at least 3 months) trial of conservative management. The records do not clearly document 
failure of exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance of prolonged 
immobility as required by the Medicare LCD L34536. The records report "some relief in symptoms" with 
compression therapy but do not document failure of exercise, periodic leg elevation, weight loss and avoidance 
of prolonged immobility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovascular ablation therapy of incompetent extremity veins have not been 
met. Therefore, we decided that the Plan does not have to pay for endovascular ablation therapy of incompetent 
extremity veins (code 36482) provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 provided on October 7, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99223. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
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 99223. Our reviewer says that the medical 
records do not support the billing of code 99223. Our reviewer found based on the documentation provided, the 
services provided on October 7, 2022, were subsequent, not initial. The services provided on October 7, 2022, 
were not comprehensive. As such, the billing of CPT 99223 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 procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 provided on October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician certification for Medicare-covered home health 
services under a home health plan of care (patient not present) (G0180) provided on September 2, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health service. You say that an Evidence of Medicare Benefits 
(EOMB) must be received before this claim can be considered. The Plan denied your request. The Plan says 
this provider is not a network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the physician certification for Medicare-covered home health 
services under a home health plan of care (patient not present) (G0180) provided on September 2, 2022, by an 
out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room visit provided January 1, 2023, by a 
non-Medicare certified provider. 
 
You asked the Plan to pay for the emergency room visit. You say that you do not understand why your visit to 
the urgent care emergency room was denied. You required the services rendered. The Plan denied your request. 
The Plan says the rendering provider does not participate in the Medicare program and is not listed on the 
Medicare-certified facility site that is allowed payment due to the pandemic. 
 
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 at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the emergency room visit provided 
January 1, 2023, by a non-Medicare certified provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for seven units of the arthrodesis services billed with procedure 
code 22614 provided on September 21, 2022. 
 
You asked the Plan to pay for seven units of the arthrodesis services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the number of units billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 7 units of CPT code 22614 are not supported in the medical record. Based on this information, we 
decided that Medicare rules for coverage of seven units of the arthrodesis services have not been met. 
Therefore, we decided that the Plan does not have to pay for seven units of the arthrodesis services billed with 
procedure code 22614 provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99223 provided on July 16, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that the medical records support the billing of 
code 99223 provided on July 16, 2022. The Plan denied your request. The Plan says that the medical records do 
not support the billing of code 99223 provided on July 16, 2022. 
 
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 99223 is Initial hospital care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and medical decision 
making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes 
are spent at the bedside and on the patient's hospital floor or unit. 
 
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 99223. Our reviewer says that the medical 
records support the billing of code 99223 provided on July 16, 2022. Our reviewer found based on the 
documentation provided, the documented history is comprehensive. The documented examination is 
comprehensive. The medical decision making was of high complexity. The billing of CPT 99223 is 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 procedure code 99223 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99223 provided on July 16, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87481, 
87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, 87798) provided on 
September 11, 2022. 
 
You asked the Plan to pay for the urine PCR panel. The Plan denied your request. The Plan says this testing 
should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This was a 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 urine PCR panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661, 
87798) provided on September 11, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided in the United Mexican States on May 25, 
2022. 
 
You asked the Plan to pay for ambulance services. You say that this service was appropriate and should be 
paid. The Plan denied your request. The Plan says that the Plan paid the full $25,000 benefit for out-of-country 
services so not further payment will be made. 
 
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. The Plan claims that the Plan has already paid the full $25,000 out-of-country 
emergency care benefit for the calendar year of 2022. However, the Plan has not submitted and documentation 
or evidence demonstrating any payment toward this benefit. Without this information, we cannot determine 
whether the $25,000 out-of-country emergency care benefit was exhausted at this time this claim was 
processed. Therefore, the plan has not shown that its decision to deny payment for these services is correct or 
justified according to the enrollees contract with the Plan. Therefore, we decided that the Plan has to pay for 
ambulance services provided in the United Mexican States on May 25, 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 the services provided on October 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says medical necessity 
cannot be determined. 
 
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. 
 
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 the services have been met. The 
submitted documentation does not contain medical records from the non-contract provider. Therefore, we 
decided that the Plan does not have to pay for the services provided on October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service July 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 27, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on October 25, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99285. 
 
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 a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 99285. Our reviewer says that the medical records do not support the billing of code 99285. Our reviewer found based on the documentation provided, the 
medical decision making was not of high complexity. The nature of the enrollees illness was not life or limb 
threatening.  As such, the billing of CPT 99285 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 procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 provided on October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the enrollee has failed to improve with 
physical therapy. You say that Tylenol and Naproxen help temporarily. You say that the enrollee does not want 
to be on pain medications. You also say that the nerve blocks will be done for diagnostic purposes to to see if 
they will help with the enrollee's chronic knee pain. The Plan denied your request. The Plan says the requested 
procedure is not medically reasonable or 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 a genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the role of genicular nerve blocks and of RFA is the subject of ongoing clinical trials. Therefore, the reviewer found that the requested genicular nerve block is not medically reasonable and 
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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Genesight test (81226) provided on November 9, 2022. 
 
You asked the Plan to pay for the Genesight test. You say that this claim has been denied in error. 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 Genesight test 
have not been met. Therefore, we decided that the Plan does not have to pay for the Genesight test (81226) 
provided on November 9, 2022.