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

 
We decided that the Plan does not have to pay for initial observation care (procedure code 99219) rendered on 
April 11, 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 Current Procedural Terminology (CPT) 99219 remains 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 99219 is Initial observation 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 moderate 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 to outpatient hospital "observation status" are of moderate severity. Typically, 50 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 in this case, the documentation 
available for review does not support the CPT code 99219. There is no indication that the three key 
components were present in the documentation to support a CPT code of 99219. The documentation does not 
support a comprehensive history was obtained. 
 
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 observation care (procedure code 99219) rendered on April 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the face down positioning device you rented on November 4, 
2022. 
 
You asked the Plan to pay for the face down positioning device. You say that you needed this item following 
vitrectomy surgery in order to sleep. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that face down positioning devices are statutorily 
non-covered because they do not fall within a Medicare benefit category.  This means that these devices are not 
covered for any reason, regardless of appropriateness of medical necessity. Therefore, we decided that the Plan 
does not have to pay for the face down positioning device you rented on November 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 13, 2022, to 
February 11, 2022. 
 You asked the Plan to pay for the home health services. You say that you were not aware that a NOA was 
required. 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 13, 2022. The NOA was not received by the Plan until September 
14, 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 13, 2022, to February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the CxBladder Monitor test (0013M) provided December 
20, 2022. 
 
You asked the Plan to pay for  the laboratory service. You say that the evidence supporting the use of 
Cxbladder Monitor as a medically necessary diagnostic service is well established and affirmed by Medicare. 
The Plan denied your request. The Plan says the Cxbladder panel remains unproven 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for  the CxBladder Monitor test (0013M) provided December 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on November 
29, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for genetic testing. You say that this letter documents the medical necessity of 
performing the DecisionDx-SCC gene expression test. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. Also, this test is not cleared or approved by the FDA. Additionally, this does not have a 
positive Technology Assessment from the DEX Diagnostics Exchange review. The DEX Diagnostics 
Exchange registry states this DecisionDx- SCC test is not covered with the MolDX program. We found no 
exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does 
not have to pay for the DecisionDx-SCC test (0315U) provided on November 29, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medical services provided on May 16, 2022. 
 
You asked the Plan to pay for the medical services. You say that it is not uncommon for multiple providers and 
specialties to see a patient on the same date. The Plan denied your request. The Plan says that this charge is 
incidental to another 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. Specifically, the Plan has offered absolutely no analysis of the case file 
documentation showing how it came to its conclusion to deny this service.  From the very limited information 
provided, it appears as though the Plan's denial was based on 'incidental' logic.  However, the Plan has failed to 
provide any argument or proof as to what service the denied service is incidental to.  The Plan has failed to 
provide evidence that the denied service is inclusive to any other service billed.  The burden is on the Plan to 
show why its denial is correct.  By failing to provide this information, we find that the Plan has net met its 
burden. Therefore, we decided that the Plan has to pay for medical services provided on May 16, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis codes A41.9 
and R65.20 rendered from July 2, 2022, to July 5, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment clinical validation 
audit was performed to help ensure that the diagnosis codes on the claim supported clinically. 
 
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 diagnosis codes A41.9 and R65.20. 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 the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that the documentation does not indicate that the treatment ordered by the treating 
medical providers supported a diagnosis code of A41.9 (Sepsis, unspecified organism) and R65.20 (Severe 
sepsis without septic shock). In this case, the documentation does not consistently and completely support the 
assigned secondary diagnoses codes. The decision to remove the secondary diagnoses codes and adjust the 
DRG is upheld.  
 
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 billed with diagnosis codes A41.9 and R65.20 rendered from July 2, 2022, to 
July 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the Cxbladder Detect test (0012M) provided December 27, 
2022. 
 
You asked the Plan to pay for  the laboratory service. You say that the evidence supporting the use of 
Cxbladder Detect as a medically necessary diagnostic service is well established and affirmed by Medicare. 
The Plan denied your request. The Plan says this service does not meet the coverage requirements. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for  the Cxbladder Detect test (0012M) provided December 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the Cxbladder Detect (0012M) provided November 16, 
2022. 
 
You asked the Plan to pay for  the laboratory service. You say that the evidence supporting the use of 
Cxbladder Detect as a medically necessary diagnostic service is well established  The Plan denied your request. 
The Plan says the Cxbladder panel remains unproven 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for  the Cxbladder Detect (0012M) provided November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for WATS 3D testing coded as 88361, 88312, 88305 and 88112 
provided March 30, 2022. You asked the Plan to pay for the diagnostic testing. You say that please get this claim reprocessed following 
Medicare policy, it should not be denied as experimental and investigational. The Plan denied your request. 
The Plan says screening for Barrett's esophagus is not a covered screening service. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the diagnostic testing, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for WATS 3D testing coded as 88361, 88312, 88305 and 88112 provided March 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services rendered on October 6, 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 an assistant surgeon is not payable for this surgery. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 22514. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met.  Therefore, we decided that the Plan does not have to pay for assistant surgeon 
services rendered on October 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36909 rendered on August 24, 2022. 
 
You asked the Plan to pay for the services. You say that the services were rendered in the best interest of the 
enrollee. The Plan denied your request. The Plan says an appropriate primary code was not found. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 36909 is an add-on code and has not been billed with an appropriate primary procedure code. 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 code 36909 rendered on August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88104 billed for date of service January 12, 
2023. 
 You asked the Plan to pay for procedure code 88104. You say that this code should be paid separately. The 
Plan denied your request. The Plan says payment for code 88104 is bundled into payment for code 88112. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88104 
is a column II code to column I code 88112. 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 code 88104 billed for date of service January 12, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88104 billed for date of service December 
28, 2022. 
 You asked the Plan to pay for procedure code 88104. You say that this code should be paid separately. The 
Plan denied your request. The Plan says payment for code 88104 is bundled into payment for code 88112. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88104 
is a column II code to column I code 88112. 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 code 88104 billed for date of service December 28, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1843, L2397) provided on October 5, 
2022. 
 
You asked the Plan to pay for the services. You say that the medical records should be reviewed to support 
medical necessity. The Plan denied your request. The Plan says the records do not show any recent injury, 
surgery, or objective evidence of instability. 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that there is no documentation of knee instability or a recent surgery. There is no clinical need for this 
brace. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis (L1843, L2397) provided on October 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 14. 2022, to May 
13, 2022. 
 You asked the Plan to pay for the home health services. You say that there is an issue with the Tax ID and this 
provider is in-network. The Plan denied your request. The Plan says the required NOA was not received. 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, you have not supplied the required NOA, so 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 April 14. 2022, to May 13, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service July 30, 
2022. 
 You asked the Plan to pay for procedure code 99292. You say that medical records were provided to support 
your claim. The Plan denied your request. The Plan says payment for code 99292 is bundled into payment for 
code 36556. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99292 
is a column II code to column I code 36556. 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 code 99292 billed for date of service July 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical equipment you purchased from an online vendor on 
August 23, 2022, and August 28, 2022. 
 
You asked the Plan to pay for the medical equipment. You say that it was necessary to purchase these items so 
that they could be received in a timely manner. You said that you were not told that you had to use a Medicare-
certified provider. The Plan denied your request. The Plan says you purchased these items from a provider who 
is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at 
issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for 
medical equipment you purchased from an online vendor on August 23, 2022, and August 28, 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 enrollee would benefit significantly from an 
intensive rehabilitation therapy program.  The Plan denied your request. The Plan says the enrollee doesn't 
meet the criteria for admission to an IRF.  
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and ordered 
by the patient's doctor. 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 provided on July 22, 2022.