Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tissue exam (88305), immunofluorescence, per 
specimen; initial single antibody stain procedure (88346), morphometric analysis; nerve (88356), 
immunofluorescence, per specimen; each additional single antibody stain procedure (88350). 
 
You asked the Plan to pre-approve testing. You say that the testing is medically necessary. The Plan denied 
your request. The Plan says the requested testing is considered experimental and investigational. There is very 
limited literature that supports the testing in a clinical setting at this time. 
 
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 testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested test does not readily reflect the current standards of care in clinical practice. Rather, the test requested in this case is not readily supported for use in formal clinical practice by any well-
designed clinical studies. Rather, the preponderance of the literature at this time is of very low evidentiary 
value. Further well-designed clinical studies are necessary to make determinations on this service. In that 
regard, the test would be experimental or investigational and therefore not covered by Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of testing have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a tissue exam (88305), immunofluorescence, per specimen; initial single antibody stain procedure 
(88346), morphometric analysis; nerve (88356), immunofluorescence, per specimen; each additional single 
antibody stain procedure (88350).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no magnetic resonance imaging 
(MRI) showing only modic changes without facet degenerative joint disease or stenosis. The cause of the 
enrollee's pain is not clear. The Intracept procedure is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed for date of service March 29, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and were 
reported appropriately. The Plan denied your request. The Plan says that no physician order was provided to 
show that these services were medically necessary and requested by the enrollees treating physician. In 
addition, these services were not billed with a date of service that is supported by the records provided. 
 
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 laboratory services have been met. 
Specifically, no physician order or notes were submitted for review. There is insufficient evidence to show that 
the services provided were requested/intended by a physician who is treating the enrollee, or that these services 
were medically necessary. In addition, the records provided reflect a specimen collection date of March 15, 
2023. The sample in question is not eligible for an exception to the general date of service rule for laboratory 
services, as this specimen is not related to cancer testing. Therefore, we decided that the Plan does not have to 
pay for laboratory services billed for date of service March 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 8, 2022, to 
May 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 8, 2022, to May 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
on April 7, 2023. 
 
You asked the Plan to pay for the unlisted molecular pathology procedure (81479). You say that the physician 
ordered molecular testing as part of the enrollee's treatment plan, which is highly beneficial in predicting 
response to treatment and improving clinical outcomes. You say that the appeal should be reviewed, and the 
denial overturned. The Plan denied your request. The Plan says the billed service cannot 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 81479 is unlisted molecular pathology 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 unlisted molecular pathology procedure (81479). Our 
reviewer says that this procedure code cannot be verified. Our reviewer found that the procedure report 
documents a testing description. However, the laboratory report does not include the testing with results to 
support the billed service. 
 
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 unlisted molecular pathology procedure (81479) have not been met. 
Therefore, we decided that the Plan does not have to pay for the unlisted molecular pathology procedure 
(81479) provided on April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 provided on May 24, 2023. 
 
You asked the Plan to pay for procedure code 99291. You say that the medical records support the billing of 
code 99291.  The Plan denied your request. The Plan says the medical records do not support the billing of 
code 99291.  
 
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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 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 procedure code 99291. Our reviewer says that the medical 
records do not support the billing of code 99291.  Our reviewer found there is no documentation to support the billing of code 99291, as there is no time statement for the critical care provided. 
 
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 99291 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99291 provided on May 24, 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 needs this care to return to prior level of 
independence. The Plan denied your request. The Plan says medical records do not support the need for an IRF 
admission and, the enrollee needs can be provided at another setting.  
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 the observation care services described by code 99224 billed 
on date of service December 23, 2022. 
 You asked the Plan to pay for 99224. You say that 99224 should be paid as billed because it is supported in the 
medical record and was billed with the correct place of service. The Plan denied your request. The Plan says 
99224 is denied because it was billed with an inappropriate place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say observation care is a 
well-defined set of specific, clinically appropriate services furnished while the decision is being made 
regarding whether an enrollee will require further treatment as a hospital inpatient or if they are able to be 
discharged from the hospital.  
 
We find that CPT code 99224 is not supported in the medical record. Specifically, 99224 is an outpatient 
hospital service code. In this case, we confirmed 99224 was billed with place of service 21, indicating an 
inpatient hospital setting. This place of service is inconsistent with observation care code 99224, which per 
Medicare rules, is reported for enrollees who require a significant period of monitoring or treatment while the 
decision regarding their admission or discharge is being made. Based on this information, we decided that 
Medicare rules for coverage of 99224 have not been met. Therefore, we decided that the Plan does not have to 
pay for the observation care services described by code 99224 billed on date of service December 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on March 23, 2023, billed with 
codes 87481, 87798 and 87801. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on March 23, 2023, billed with codes 87481, 87798 and 87801.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel provided on March 14, 
2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the claim is not payable 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The UTI panel in this case was billed with multiple codes and not 
one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
urinary tract infection (UTI) panel provided on March 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2023, to July 15, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2023, to July 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 21, 2023, billed with 
codes 87481, 87491, 87653, 87591, 87640, 87653, 87661, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. 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. The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single 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 April 21, 2023, billed with codes 87481, 87491, 87653, 87591, 
87640, 87653, 87661, and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service March 21, 2023. 
 
You asked the Plan to pay for code 99223. You say that this claim was denied as a duplicate in error. 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 26, 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 code 99223 have not been met. Therefore, 
we decided that the Plan does not have to pay for code 99223 billed for date of service March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 28, 2023, billed with 
procedure code 99152. 
 
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 documentation does not support the billed code 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older.  
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that there is no documentation to support 
the 99152, as there is no time and observance statements in the note to support the 99152. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on June 28, 2023, billed with procedure code 
99152.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 31, 2022, to 
April 7, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis codes A41.9 and G92.8, 
described as sepsis, unspecified organism, and other toxic encephalopathy. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that documentation does not support the billed codes. Our physician reviewer found that the documentation 
does not support that systemic inflammatory response syndrome criteria are met, or that altered mental status 
was due to metabolic derangements, so neither code A41.9 nor G92.8 are supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 31, 2022, to April 7, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy services on June 06, 
2023.  
 
You asked the Plan to waive the coinsurance for the chemotherapy services. You say that you were not made 
aware that you would have a cost for clinically administered medication. 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 0% or 
20% coinsurance for Medicare Part B drugs when administration or observation by medical personnel is 
required and the drugs are administered to you by a network provider. Please call Member Services to find out 
which drugs are provided at the 20% coinsurance. The provider billed in the amount of $19,754.65 and the 
allowed amount is $11,970. For the services it's, $11,970 x 20% = $2,394. Therefore, results in the total cost 
sharing amount of $2,394. 
 
You have been asked to pay a 20% coinsurance for the chemotherapy services. This item/service falls within 
the Medicare Part B prescription drugs 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. Therefore, we decided that the Plan does not have to waive the coinsurance 
for the chemotherapy services on June 06, 2023.