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

 
We decided that the Plan has to pay for procedure code 99233 for date of service September 27, 2022. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the services billed are not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan has denied this code stating that the 
payment for this service is included in the fee for the procedure. No explanation was provided on what 
procedure this service is included in. No other denial rationale was provided. The Plan did not substantiate their 
denial. Therefore, we decided that the Plan has to pay for procedure code 99233 for date of service September 
27, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 2, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
2, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve lab services provided from March 23, 2022, to March 30, 2022. 
 
You asked the Plan to pre-approve the lab services. You say that you believe these services were billed 
correctly. The Plan denied your request. The Plan says that the procedures codes bill are inconsistent with the 
modifier used or the modifier is missing. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided minimal information in the case file it 
submitted to us. The Plan provider no denial rationale or analysis for its denial beyond sending us a copy of the 
provider remittance.  There is no citation to any rule upon which its denial was based.  The Plan has failed to 
identify what modifier, specifically, is incorrect or missing.  The Plan has failed to address how it came to this 
conclusion.  The burden is on the Plan to show why its denial is correct.  By failing to provide any of this 
information in the case file it submitted to us, we find that the Plan has not met this burden. Therefore, we 
decided that the Plan has to pre-approve lab services provided from March 23, 2022, to March 30, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 2, 2022, to 
March 31, 2022. 
 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 NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 2, 2022. The NOA was not received by the Plan until December 19, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from March 2, 2022, to March 31, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for imaging services provided on December 21, 2022, billed with code 
93005. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that the services were billed with an invalid place 
of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the Electrocardiogram was performed during an urgent care visit, 
and POS 20 is correct for the interpretation of the Electrocardiogram. Therefore, we decided that the Plan has 
to pay for imaging services provided on December 21, 2022, billed with code 93005.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 5, 2022, to 
February 3, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 5, 2022. The NOA was not received by the Plan until March 10, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 5, 2022, to February 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 28, 2022, to 
February 1, 2022. 
 You asked the Plan to pay for the home health services. You say that you have supplied to required NOA. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 28, 2022. The NOA was not received by the Plan until February 
27, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from January 28, 2022, to February 1, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on January 5, 2023. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is not enrolled to be eligible to bill 
Medicare.  
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on January 5, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the manual spinal manipulation billed under code 98941. We 
decided that the Plan does not have to pay for all other services provided by the chiropractor.  
 
You asked the Plan to pay for the chiropractic spinal manipulation (98941) and other services provided by a 
chiropractor (99203, G0283, 97026, S9090) provided from September 19, 2022, through October 26, 2022. You say that this should be paid as the services are covered by Medicare.  The Plan says that the services 
rendered do not meet coverage criteria.  
 
We decided that the Plan has to pay for the manual spinal manipulation billed under code 98941.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation when there is an expectation of improvement in 
function.   
 
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 manual spinal manipulation billed under 
code 98941. Our reviewer says that the chiropractic manipulations provided are reasonable and necessary as 
the enrollee had a covered diagnosis. Our physician reviewer found the enrollee had listed diagnoses of 
Spondylolisthesis, lumbar region, Spondylolysis, lumbosacral region, and Spondylolysis, lumbosacral region. 
On September 16, 2022, it is documented that the enrollee had degenerative lumbar spine both joint and disc 
disease. Spinal Stability/Restrictions(s)/Subluxation(s) were noted at L4, L5, and sacrum.   
 
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 manual spinal manipulation billed under code 98941 have been met. 
Therefore, we decided that the Plan has to pay for the manual spinal manipulation billed under code 98941.  
 
We also decided that the Plan does not have to pay for all other services provided by the chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 
 
We looked at the file and Medicare rules. The other services provided were not manual manipulation of the 
spine and cannot be covered by Medicare. Based on this information, we decided that Medicare rules for 
coverage of all other services provided by the chiropractor have not been met. Therefore, we decided that the 
Plan does not have to pay for all other services provided by the chiropractor. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307, G0480) provided on August 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are 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 (80307, G0480) provided on August 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on December 5, 
2022. 
 
You asked the Plan to pay for the bacterial urine culture. You say that this service was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted 
with a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 87086. Any codes which are not listed are considered not medically necessary for 
code 87086. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine culture have not been met. Specifically, this claim was submitted with a diagnosis code which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we 
decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on December 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneDose genetic response report (comprehensive 
hereditary pharmacogenomic testing) and hereditary genetic cardiac test panel (81225, 81226, 81227, 81231, 
81232, 81328, 81240, 81241, 81291, 81306, 81238 and 81335) provided December 23, 2022. 
 You asked the Plan to pay for the genetic testing. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says there is 
insufficient records to support that the enrollee meets the criteria. 
 
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. 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 
GeneDose genetic response report (comprehensive hereditary pharmacogenomic testing) and hereditary genetic 
cardiac test panel (81225, 81226, 81227, 81231, 81232, 81328, 81240, 81241, 81291, 81306, 81238 and 
81335) provided December 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on February 25, 2022. 
 
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 documentation does not support these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 review indicates that the the 
records supported a comprehensive history and examination but did not support medical decision making of 
high complexity. The records did not support the presenting problems were of high severity, posing an 
immediate significant threat to life and function. 
 
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 emergency room services (procedure code 99285) rendered on February 25, 2022.
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 January 1, 
2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
ordered by a network physician. 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 January 1, 2023, to January 28, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the SelectMDx testing provided on January 17, 2023. 
 
You asked the Plan to pay for the SelectMDx testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says that this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare 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 DEX Diagnostics Exchanges shows that this testing is 
listed as covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the 
SelectMDx testing have been met. Therefore, we decided that the Plan has to pay for the SelectMDx testing 
provided on January 17, 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 pay for the pneumatic compression device (PCD) coded E0675 
billed for June 13, 2022, to July 5, 2022. 
 
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. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (PCD) coded E0675 billed for June 13, 2022, to July 5, 2022.
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 the 
enrollee's needs. The Plan denied your request. The Plan says the enrollee's needs may be met with less 
frequent therapy services in a long-term care facility.  
 
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 does 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.