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

 
We decided that the Plan does not have to pay for 7 additional units of procedure code 88341 rendered on April 
19, 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 there was no specific rational for why the additional services needed to be performed.  
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 88341 is "Immunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure)." 
 
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 surgical pathology for a right 
neck excision of a lymph node was completed. 20 units of procedure code 88341 were performed, out of the 
allowed/covered 13 units. The records reveal that 13 units were already reimbursed for this same date. Also, 
there was no documented explanation as to why the extra units were needed for this patient. The records do not 
clearly support that the additional units were actually rendered in this case, nor was there sufficient support 
made for them as reasonable or necessary for this enrollee on the above date.  
 
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 7 additional units of procedure code 88341 rendered on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis skin substitute. 
 
You asked the Plan to pre-approve Kerecis skin substitute. You say that Kerecis skin substitute is medically 
necessary. The Plan denied your request. The Plan says the requested Kerecis skin substitute 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 pre-approve Kerecis skin substitute. Our reviewer 
says that the requested Kerecis skin substitute is not considered medically reasonable and necessary. Our 
physician reviewer found that the records did not include information regarding follow-up after Moh's surgery 
indicating state of wound and need for skin substitute to manage healing as opposed to standard management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Kerecis skin substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Kerecis skin substitute.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 17, 2023, billed with 
procedure code 00300. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an inappropriate 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. Codes for unspecified side should 
rarely be used without obtaining physician clarification. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. We find that diagnosis code H57.819 is not 
appropriate as a more specific code should be used. Therefore, we decided that the Plan does not have to pay 
for practitioner services provided on April 17, 2023, billed with procedure code 00300.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transport and ground mileage 
provided on August 11, 2023. 
 
You asked the Plan to pay for non-emergent ambulance transport and ground mileage. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says the enrollee did not require the 
expertise of trained personnel or the equipment available only in an ambulance in order to effectuate a safe 
transport. While the enrollee is noted to be unable to ambulate due to weakness and requires oxygen via nasal 
cannula, transportation could have been provided by other means. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 non-emergent ambulance transport and 
ground mileage. Our reviewer says that the enrollee does not meet the criteria for non-emergent ambulance 
service and ground mileage. Our physician reviewer found the records do not indicate that the enrollee's 
clinical condition was such that other methods of transport, such as stretcher van, are contraindicated, or that 
the expertise, services and lifesaving equipment that only a fully-equipped ambulance can provide 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 non-emergent ambulance transport and ground mileage have not been met. 
Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport and ground 
mileage provided on August 11, 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 enrollee meets the full criteria for an IRF stay. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay, with an interdisciplinary approach to rehabilitation care. The enrollee 
does 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 and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve superficial electronic brachytherapy. 
 
You asked the Plan to pre-approve brachytherapy. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is not enough data regarding this service to show its safety and efficacy. 
 
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 brachytherapy. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is not a standard 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 brachytherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve superficial electronic brachytherapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right eye blepharoplasty surgery.  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested 
service.  
 
The Plan follows Medicare rules. The rules say that blepharoplasty, blepharoptosis repair, and brow ptosis 
repair (brow lift) are surgeries that may be functional (i.e., to improve abnormal function) and therefore 
reasonable and necessary, or cosmetic (i.e., to enhance appearance).  
 
 
 
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 this service. Our reviewer says that you 
do not meet criteria for coverage of the requested service. Our physician reviewer found that the Margin Reflux 
Distance (MRD) written was the Oculus Dexter (OD) (right eye) of 4.0 mm and the Oculus Sinister (OS)  
(left eye) of 2.0 mm, which is greater than the minimum required 2.0 mm or less for the OD. The visual fields 
testing was not submitted but interpreted as OD and OS untaped 20 degrees and taped 60 degrees, equally, 
although it is clear on the eye exam and photos that the dermatochalasis is worse for the left eye. The color 
photos are submitted of the frontal view with MRD >2.0 mm for the right eye. The photos do not show upper 
eyelid skin resting on the eyelashes nor over the eyelid margin for the right eye. They did not demonstrate 
excessive dermatochalasis pushing the eyelid margin down to an abnormally low position. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right eye blepharoplasty surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64447, 64450 and 76942 billed for date of 
service January 30, 2023. 
 
You asked the Plan to pay for procedure codes 64447, 64450 and 76942. You say that the services were billed 
correctly. The Plan denied your request. The Plan says payment for the services at issue is bundled into 
payment for other codes. 
 
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 code 64447 and 64450 are column II codes to column I code 01402; 
however, 64447 and 64450 were billed with a 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 codes 64447, 64450 and 76942. Our reviewer says 
that procedure codes 64447, 64450 and 76942 do not meet the criteria for coverage. Our reviewer found the 
procedure report was not in the documentation to confirm procedure codes 64447 and 64450 were performed 
or that they were unbundled services. In addition, the documentation states anesthesia and a regional block 
were performed. However, sufficient documentation was not included to confirm procedure code 76942 was 
performed or that this service was not part of the anesthesia. 
 
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 64447, 64450 and 76942 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 64447, 64450 and 76942 billed for date of 
service January 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 2, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the diagnosis code at 
issue is not appropriate as a primary diagnosis.  
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code I46.2. This code is 
not an appropriate primary diagnosis as the code has a Code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for the services provided on July 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC gene expression test (0315U) provided 
July 26, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that your claim for the DecisionDx-SCC test was 
denied in error and you are requesting it be reprocessed and paid. The Plan denied your request. The Plan says 
this test is not covered by Medicare. 
 
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. Per the DEX Diagnostics Exchange Registry, this testing has been 
evaluated by the Molecular Diagnostic Tests (MolDX) Program and is considered non-covered at this time. 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 DecisionDx-SCC gene expression test 
(0315U) provided July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 81404 and 81405 
for date of service March 6, 2023. 
 
You asked the Plan to pay for the laboratory services billed with codes 81404 and 81405. 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 codes 81404 and 81405 have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services billed with codes 81404 and 81405 for date of service March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0114U) provided on June 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (0114U) provided on June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve JAK2 (Janus kinase 2) (e.g., myeloproliferative 
disorder) targeted sequence analysis (e.g., exons 12 and 13) (81279). 
 
You asked the Plan to pre-approve the laboratory testing. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says based on Medicare 
guidelines, the requested genetic testing, JAK2 Exon 12 Mutation Analysis 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 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 laboratory testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had a platelet count of 564 and hematocrit was 40 in August 2023, and a 
repeat hematocrit in September 2023 was 42. There also is no documentation of concern for polycythemia vera 
(PV).  According to the LCD, one needs to meet the WHO's diagnostic criteria for PV if JAK2, exon 12 were 
positive. Therefore, this does not meet the above criteria.  
 
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 laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) targeted sequence 
analysis (e.g., exons 12 and 13) (81279).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 81595 provided on July 5, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services billed with code 81595 provided on July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93005, 96372, and 93041 for date of service 
June 26, 2023. 
 
You asked the Plan to pay for procedure codes 93005, 96372, and 93041. 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 codes 93005, 96372, and 93041 are not payable as billed. Specifically, codes 93005, 93041, 
and 96372 are assigned a Q1 indicator (Packaged APC payment if billed on the same claim as a HCPCS code 
assigned status indicator S, T, or V"). CPT code 99285 25 was assigned final status indicator V since the 
APC assigned was 5025. These services are not separately payable as billed. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 93005, 96372, and 93041 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 93005, 96372, and 93041 for date 
of service June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 5, 2023.

You asked the Plan to pay for these services. The Plan denied your request. The Plan says this testing is not
typically performed for recurrent urinary tract infections. Maximus overturned the Plan's denial stating the
testing was ordered by a Plan provider. The Plan requested a reopen and noted that there are insufficient
records provided to explain why genetic testing was needed due to recurrent urinary tract infections.

The Plan is correct in this case. 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.

Medicare rules say screening lab services without documentation of medical necessity are not covered.
We looked at the file and Medicare rules. The reason stated for this genetic testing is recurrent urinary tract
infections. Based on this information, we decided that there is insufficient information in the record to
determine if Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan
does not have to pay for lab services provided to the enrollee on January 5, 2023.