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

 
We decided that the Plan has to pay for the lab services provided from October 3, 2022, to November 21, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the claim must 
be submitted to the Independent Physicians Association (IPA) for processing. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the lab services by a contract provider. The file does not show that the plan 
provided notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the lab services provided 
from October 3, 2022, to November 21, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70491-26) and the CT scan (70470-26) 
provided on February 4th, 2023. 
 
You asked the Plan to pay for computed tomography scan. You say that CPT code(s) 70470-26 and 70491-26 
was not bundled with any other procedure code done on the same date of service. You say that medical records 
submitted supports CPT code(s) 70470 and 70491 and should be paid. The Plan denied your request. The Plan 
says CPT code 70491-26 is a column II to column I code 70498-26, and CPT Code 70470-26 is a column II to 
column I code 0042T. A modifier was not billed on the claim to represent the services as separate/distinct. 
Therefore, the determination for code 70491-26 and 70470-26 is to uphold the original denial. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
70491-26 and 70470-26 are column II codes to column I codes 70498 and 0042T. This claim has not been 
billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) 
scan of the head or brain; without contrast material, followed by contrast material(s) (70491-26) and computed 
tomography (CT) scan of soft tissue in the neck; with contrast material(s) (70470-26) provided on February 
4th, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87500, 87641, 87653, 87798, 
and 87801 rendered on January 13, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 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 there is a more specific procedure 
code to use that covers a urinary tract infection (UTI) panel. Additionally, in terms of CPT 87641, 87653, and 
87798, these codes should not be reported separately from CPT 87801. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87150, 87481, 87500, 87641, 87653, 87798, and 87801 rendered on January 
13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798, billed for date of 
service November 16, 2022. 
 You asked the Plan to pay for procedure codes 87481, 87653, and 87798. The Plan denied your request. The 
Plan says payment for codes 87481, 87653, and 87798 is bundled. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87481, 87653, and 87798 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798, 
billed for date of service November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 22, 2023, billed with 
procedure codes 58262-AS, 57240-AS-51, and 57288-AS-51. 
 
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 services were billed outside scope of the provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for practitioner services provided on 
March 22, 2023, billed with procedure codes 58262-AS, 57240-AS-51, and 57288-AS-51.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan (76770, 93975) provided on January 10, 2023. 
 
You asked the Plan to pay for the duplex scan. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 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 duplex scan. Our reviewer says that the billed service is 
not supported by the provided records. Our reviewer found the medical records do not support codes 76770 and 
93975. There is a more appropriate code that can be used to properly capture the exam performed. 
 
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 duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pay for a duplex scan (76770, 93975) provided on January 10, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 87506 for date of service April 7, 2023. 
 
You asked the Plan to pay for procedure code 87506. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that the service billed is included in the facility services for the billed 
date 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. The Plan states that the service billed is included in the facility services for the 
billed date of service. However, the documentation does not include the facility services that code 87506 is 
included in. No medical records or claims from other services for this date of service were submitted for 
review. No other explanation/denial rationale was provided. Therefore, the Plan did not substantiate their 
denial. Therefore, we decided that the Plan has to pay for procedure code 87506 for date of service April 7, 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, 87798, and 87801 billed for 
date of service January 12, 2023. 
 You asked the Plan to pay for procedure codes 87481, 87653, 87798, and 87801. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered 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. In this case, we have confirmed that codes 
87481, 87653, and 87798 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. The -XU modifier is not supported as a separate and distinct procedural 
service. Based on the claim submitted, Medicare billing criteria have not been met. 
 
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 87801 is infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) technique. We find that CPT code 87801 is not supported in the medical record. Specifically, the 
records show that multiple infectious agent detection was performed but the number of units billed is not 
supported. 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 procedure codes 87481, 87653, 87798, and 87801 
billed for date of service January 12, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 16, 2022, to July 
15, 2022. 
 You asked the Plan to pay for the home health services. You say that you have submitted 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 May 17, 2022. The NOA was not received by the Plan until July 21, 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 
June 16, 2022, to July 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 22, 2022, to 
March 23, 2022. 
 You asked the Plan to pay for the home health services. You did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says a valid 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 February 22, 2022. The NOA was not received by the Plan until June 1, 
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 February 22, 2022, to March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 20, 
2023. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
code 99100 is considered bundled and not separately payable.  
 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 0315U) rendered on 
March 3, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of Healthcare Common Procedure Coding System (HCPCS) code 
0315U is "Oncology (cutaneous squamous cell carcinoma), mRNA gene expression profiling by RT-PCR of 40 
genes (34 content and 6 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm 
reported as a categorical risk result (ie, Class 1, Class 2A, Class 2B)." 
 
 
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 no provider records are identified 
for review.  As such, there is no documentation showing that the test was medically necessary to diagnosis or 
treat the enrollee.  The cancer was diagnosed over a year prior (1/2022).  It is unclear how this new testing 
(3/2023) played a role in diagnosis or treatment.  The provided test was not medically necessary or reasonable. 
 
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 laboratory services (procedure code 0315U) rendered on March 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
December 24, 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 records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 documented history is not 
comprehensive. The documented examination is not comprehensive. The medical decision making is  problem 
focused and straight forward.  As such, the billing of CPT 99223 is not supported 
 
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 initial hospital care (procedure code 99223) rendered on December 24, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve denosumab (Prolia). 
 You asked the Plan to pre-approve the medication. You say that the enrollee cannot tolerate oral 
bisphosphonates due to a history of gastroesophageal reflux disease (GERD). The Plan denied your request. 
The Plan says step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our reviewer says that 
the criteria for coverage of denosumab have not been met. Our physician reviewer found the Plan requires a 
trial of an injectable bisphosphonate before they will approve the requested drug. The documentation does not 
support that the enrollee has had a trial of an injectable bisphosphonate such as Pamidronate, Zoledronic acid 
or Ibandronate. The documentation also does not support that an injectable bisphosphonate would likely be less 
effective or have adverse effects for the enrollee in this case. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve denosumab (Prolia).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excision or destruction of a lesion in the nose through 
an internal approach (30117). 
 
You asked the Plan to pre-approve excision or destruction of a lesion in the nose through an internal approach. 
You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for 
reasonable and necessary are not met. 
 
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 excision or destruction of a lesion in the 
nose through an internal approach. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has not been 
diagnosed with a lesion in the nose. It has not been sufficiently demonstrated that excision or destruction of a 
lesion in the nose through an internal approach produces long-lasting results in this setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of excision or destruction of a lesion in the nose through an internal approach have 
not been met. Therefore, we decided that the Plan does not have to pre-approve excision or destruction of a 
lesion in the nose through an internal approach (30117).
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 will need to continue intensive therapy 
in order to get back to baseline. The Plan denied your request. The Plan says the services the enrollee needs can 
be provided safely in other settings. 
 
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, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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.