Persius/hicric huggingface dataset:
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 18, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guidance for arthroplasty. 
 
You asked the Plan to pre-approve image guidance. You say that you are appealing the denial. The Plan denied 
your request. The Plan says that image guidance is considered an experimental or investigational procedure and 
is not covered under Medicare. 
 
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 image guidance. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that image-guided arthroplasty has not shown better outcomes than conventional open surgery. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of image guidance have not been met. Therefore, we decided that the Plan does 
not have to pre-approve image guidance for arthroplasty.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve molecular genetic testing for the APOE gene (81401). 
 
You asked the Plan to pre-approve APOE gene testing. You say that this testing is necessary to determine if the 
enrollee is appropriate for medication, underlying risk factors and further treatment options. The Plan denied 
your request. The Plan says this testing is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the APOE gene is unlikely to impact 
therapeutic decision-making, directly impact treatment, outcome and/or clinical management in the care of the 
beneficiary and will be denied as not medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of APOE gene testing have not been met. Therefore, we decided that the Plan does not have to pre-
approve molecular genetic testing for the APOE gene (81401).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says the LTACH services 
requested do not meet the requirements for approval. 
 
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 does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous at this time and completion of treatment at the current facility is recommended. 
 
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 long term acute care hospital (LTACH) services.
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 LTACH services. You say that the enrollee needs LTACH care. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not 
require a transfer to an LTACH. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation provided does not support that the enrollee requires services 
at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified, that are available at the LTACH, that the enrollee requires that are not available at the current health care setting being offered by the Plan. The enrollee is receiving acute hospital 
care and acute services have not been denied. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Novabone. 
 
You asked the Plan to pre-approve a Novabone. You say that the enrollee would benefit from this surgery. The 
Plan denied your request. The Plan says this surgery 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 a Novabone. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no literature showing that Novabone is better than conventional structural allograft in 
cervical spine surgery.  
 
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 Novabone have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Novabone.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (81226) provided on March 8, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed code is 
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 81226 is "CYP2D6 (cytochrome P450, family 2, 
subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, 
*10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN)".. 
 
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 lab services. Our reviewer says that the use of code 
81226 is not supported by the records provided. Our reviewer found that the medical documentation in this case does not support the use of 81226, nor does the billed diagnosis support medical necessity. 
 
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services (81226) provided on March 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 12, 2022, billed 
with codes 81307, 81311, 81317, 81320, 81321, 81334, 81339, 81345, 81216, 81223, 81238, 81241, 81242, 
81249, 81250, 81279, 81209, 81298, and 81305. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS 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 genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 12, 2022, billed with codes 81307, 81311, 81317, 81320, 81321, 81334, 81339, 81345, 81216, 
81223, 81238, 81241, 81242, 81249, 81250, 81279, 81209, 81298, and 81305.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 for date of service June 8, 2023. 
 
You asked the Plan to pay for procedure code 99214. 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 26040 
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 code 99214 
for date of service June 8, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for code 81456 billed for date of service August 6, 2023. 
 
You asked the Plan to pay for code 81456. You say that the NCCI has agreed to change the NCCI indicator to 
One, which would allow payment for these two codes together. The Plan denied your request. The Plan says 
that payment for code 81456 is bundled into payment for code 81455. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS has changed the NCCI PTP indicator 
between codes 81456 and 81455 to 1, meaning that payment may be made for code 81456 separately from 
81455 if billed with an appropriate modifier. In this case, you billed code 81456 with the 59 modifier, which 
makes this code separately payable under the new CMS rule.  Further, the Plan has provided no argument that 
the use of the 59 modifier in this case was not appropriate. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 81456 have been met. Therefore, we decided that the Plan has to pay for code 81456 billed 
for date of service August 6, 2023.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a negative pressure wound therapy 
(NPWT) pump. 
 
You asked the Plan to pre-approve NPWT pump. You say that your healing process will be interrupted with 
high risk of infection. The Plan denied your request. The Plan says the records do not show a signed order for 
continued care, what additional methods have been taken to address wound healing, or why alternative 
treatment alone is insufficient. 
 
The Plan follows Medicare rules. Medicare rules state that continued use of a NPWT pump may be covered if 
certain criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve NPWT pump. Our reviewer says that 
you do not meet criteria for continued treatment. Our physician reviewer found there is not a signed order to 
continue with this treatment. Additionally, you have been treated with the NPWT for more than 4 months. 
Therefore, continued use of the NPWT is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NPWT pump have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued use of a negative pressure wound therapy (NPWT) pump.
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 LTACH care is necessary. The Plan 
denied your request. The Plan says LTACH care is not medically necessary. 
 
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 patient does not require services at the LTACH that are not available at the acute 
care hospital. There are no services available at the LTACH that the patient requires that are not available at the 
health care setting being offered by the health plan. Given there are offered alternatives, LTACH care is not 
medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 6, 2023, billed with 
procedure code 99214-95. 
 
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 this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 29, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the practitioner services provided have not 
been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on April 
6, 2023, billed with procedure code 99214-95.
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 would benefit from inpatient 
rehabilitation facility services The Plan denied your request. The Plan says the inpatient rehabilitation facility 
services are not medically necessary.  
 
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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies 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. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial and subsequent hospital inpatient care billed with 
codes 99223 and 99233 provided on May 2, 2023, to May 6, 2023. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services provided should be paid. 
The Plan denied your request. The Plan says the medical records do not include the actual DOS. This means the 
validity and accuracy of the claim can't be verified. 
 
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 inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. The CPT Code Manual definition of code 99233 is subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
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 inpatient hospital care. Our reviewer found the 
documentation does not support a medical decision of high complexity and does not support the date of service 
(DOS) the procedure was performed. Therefore, code 99223 and 99233 is not supported for the DOS reported. 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the initial hospital inpatient or observation care, per day, for the evaluation and 
management of a patient, which requires a medically appropriate history and/or examination and high level of 
medical decision making. When using total time on the date of the encounter for code selection, 75 minutes 
must be met or exceeded and subsequent hospital inpatient or observation care, per day, for the evaluation and 
management of a patient, which requires a medically appropriate history and/or examination and high level of 
medical decision making. When using total time on the date of the encounter for code selection, 50 minutes 
must be met or exceeded billed with codes 99223 and 99233 provided on May 2, 2023, to May 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for the walker on June 2, 2023.  
 
You asked the Plan to increase the reimbursement for the walker. You say that you would like full 
reimbursement for the purchase of durable medical equipment. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 25% 
coinsurance for out-of-network durable medical equipment provider. 
 
 
 
 You have been asked to pay a 25% coinsurance for the walker. This item/service falls within the durable 
medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. You were reimbursement up to the full Medicare allowed amount 
minus the 25% coinsurance. Therefore, we decided that the Plan does not have to increase the reimbursement 
for the walker on June 2, 2023.