Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code Q0092 for date of service June 22, 2023. 
 
You asked the Plan to pay for code Q0092. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 Q0092 is set-up portable x-ray equipment. 
 
We find that CPT code Q0092 is not supported in the medical record. Specifically, the documentation did not 
include medical records. This means this service billed is not supported. Based on this information, we decided 
that Medicare rules for coverage of code Q0092 have not been met. Therefore, we decided that the Plan does 
not have to pay for code Q0092 for date of service June 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81479 for date of 
service August 7, 2023. 
 
You asked the Plan to pay for the laboratory services billed with code 81479. You say that you disagree with 
the Plan's denial. 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 services 
billed with code 81479 have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services billed with code 81479 for date of service August 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81455 provided on 
February 22, 2023. 
 
You asked the Plan to pay for the laboratory services billed with code 81455. You say that you disagree with 
the Plan's denial. 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 services 
billed with code 81455 have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services billed with code 81455 provided on February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
July 25,2023. 
 
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. The rules say that urinalysis is the standard of care for a urinary tract 
infection (UTI). 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. 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 
urine polymerase chain reaction (PCR) panel rendered on July 25,2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88368, 88369, 88377, 81270, 81279, 81338, 
81219, 81334, 81176, 81347, G0452, 81403, and 81405 billed for date of service January 30, 2023. 
 
You asked the Plan to pay for procedure codes 88368, 88369, 88377, 81270, 81279, 81338, 81219, 81334, 
81176, 81347, G0452, 81403, and 81405. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says payment for codes 88368, 88369, and 88377 are bundled into payment for code 
81403. The Plan also says that services were billed as unbundled panel codes. The Plan says that codes 81403 
and 81405 are 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, we have confirmed that codes 
88368, 88369, and 88377 are column II codes to column I code 81403. This claim has not been billed with an 
appropriate modifier to bypass the edit. 
 
Codes 81270, 81279, 81338, 81219, 81334, 81176, 81347 and G0452 were billed for a HemeScreen panel 
performed on the same peripheral blood specimen. The billing of these individual codes has been identified as 
incorrect coding as they were billed unbundled. A panel code would be more appropriate to be billed for these 
services. 
 
Code 81403 is defined as molecular pathology procedure level 4; tests are used to analyze nucleic acid for 
abnormalities that may be indicative of a variety of disorders. The documentation did not include results to 
support this billed code. Code 81405 is described as molecular pathology procedure level 6; tests are used to 
analyze nucleic acid for abnormalities that may be indicative of a variety of disorders. The documentation did 
not include results to support this billed code. 
 
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 88368, 88369, 88377, 81270, 81279, 81338, 81219, 81334, 81176, 
81347, G0452, 81403, and 81405 billed for date of service January 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided support the 
need for the requested LTACH admission. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care and does not require transfer to a long term acute care hospital. 
 
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 was admitted with acute on chronic systolic congestive heart failure and 
bacteremia. The record indicates that 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 not currenly receiving but that would be 
available at the LTACH facility. The elements of coverage are not satisfied. 
 
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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ottobock Kenevo microprocessor knee. 
 
You asked the Plan to pre-approve the microprocessor knee. You say that the current knee unit does not 
provide stability or function the way a microprocessor knee unit will provide. The Plan denied your request. 
The Plan says the requested microprocessor knee exceeds the member's needs. 
 
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 microprocessor knee. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation indicates the enrollee has a current K3 knee that is still under 
warranty. The documentation does not support that the current knee, which is less than a year old, and therefore 
under warranty, will not meet the enrollee's needs. The prosthetist's (vendor's) notes allege need for a new knee 
as the enrollee has an ill-fitting socket and falls, however the documentation does not indicate that the enrollee 
is unable to safely perform current activities with the new socket. The enrollee's current activities can be met 
with a mechanical knee. There is no documented physiologic change requiring new prosthetic knee; no 
irreparable change to the knee is documented; no documentation of repairs for the knee is documented. 
Furthermore, the physician documentation is conflicting as the CPO (certified prosthetist/orthotist) states the 
enrollee has had multiple falls due to the knee collapsing. A September 8, 2023, physician medical progress 
note states the enrollee has had no falls in the past year. Additionally, the requested Ottobock Kenevo knee has 
features that exceed the enrollees medical and functional needs such as an intuitive indoor bicycle function, 3 
activity modes, a donning function, and charging with a foam cover. The enrollee's needs can be safely and 
effectively met with a less complex knee. 
 
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 microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Ottobock Kenevo microprocessor knee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that Eylea is medically necessary. The Plan denied your 
request. The Plan says a trial of Bevacizumab is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that this drug 
is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drugs, 
or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 for date of service June 20, 2023. 
 
You asked the Plan to pay for procedure code 83789. 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 performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 83789 have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for procedure code 83789 for date of service June 20, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97110, 97116, and 97530 rendered on July 
31, 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 denied codes remain 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 the denied codes is: 
 
CPT 97110: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility 
 
CPT 97116: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) 
 
CPT 97530: 
 
Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal 
preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) 
direct one-on-one contact, each 15 minutes 
 
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 documentation does not 
include sufficient documentation to verify the time spent for these procedures. 
 
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 97110, 97116, and 97530 rendered on July 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for you to 
receive therapy services to relearn how to walk after an amputation. The Plan denied your request. The Plan 
says you do not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure 99203 for date of service February 16, 2023. 
 
You asked the Plan to pay for procedure 99203. You say that you disagree with the Plan's denial. 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. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 11042 
provided on the same date of service. 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 99203 for 
date of service February 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
August 25, 2023, and billed with codes 87481, 87651, 87653, G0452, 87500, 87641, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. 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 panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test 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 
provided on August 25, 2023, and billed with codes 87481, 87651, 87653, G0452, 87500, 87641, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies and the needle electromyogram 
provided on July 27, 2022. 
 
You asked the Plan to pay for the nerve conduction studies and the needle electromyogram. You say that you 
are requesting reconsideration of the denied claim. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nerve conduction 
studies and the needle electromyogram provided on July 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing, 15-21 classes, performed on 
April 12, 2023. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the number of classes requested is 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that extensive drug testing was required. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for definitive urine drug testing, 15-21 classes, performed on April 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an over-the-counter (OTC) COVID-19 test provided on July 
12, 2023. 
 
You asked the Plan to pay for the OTC COVID-19 test. The Plan denied your request. The Plan says OTC 
COVID-19 tests are not covered by Medicare after May 11, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for OTC items, including 
self-administered COVID-19 tests. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the OTC COVID-19 test have not been met. Therefore, we decided that the Plan does not have to 
pay for an over-the-counter (OTC) COVID-19 test provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies provided on July 7, 2023, by an out-of-network 
(OON) provider.  
 
You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says the services were not 
approved. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the supplies provided on July 7, 2023, by an out-of-network 
(OON) provider.