Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 21, 2023. 
 
You asked the Plan to pay for the services. 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 services at issue were reimbursed 
by the Plan on May 18, 2023. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the services have not been met. Therefore, we decided that 
the Plan does not have to pay for the services provided on April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87486, 87496, 87498, 87502, 87532, 87541, 
87581, 87640, 87651, and 87798 billed for April 18, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the codes are 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 87486 is infectious agent detection by nucleic acid (DNA 
or RNA); Chlamydia pneumoniae, amplified probe technique. The definition of code 87496 is infectious agent 
detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique. The definition 
of code 87498 is infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe 
technique, includes reverse transcription when performed. The definition of code 87502 is infectious agent 
detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse 
transcription when performed. The definition of code 87532 is infectious agent detection by nucleic acid (DNA 
or RNA); Herpes virus-6, amplified probe technique. The definition of code 87541 is infectious agent detection 
by nucleic acid (DNA or RNA); Legionella pneumophila, amplified probe technique. The definition of code 
87581 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe 
technique. The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); 
Staphylococcus aureus, amplified probe technique. The definition of code 87651 is infectious agent detection 
by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique. The definition of code 
87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism.  
 
We find that CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, and 87798 are not 
supported in the medical record. Specifically, the records show that a panel was performed and there is a more 
appropriate single code for the services. 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 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87640, 87651, and 87798 billed for April 
18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87652, 87798, 87899, and 
87900 billed for date of service November 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the codes are valid and payable. The Plan denied 
your request. The Plan says there are no results for these codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that a urinary tract infection panel with organism identification and susceptibility was ordered. 
We find that CPT codes 87481, 87640, 87652, 87798, 87899, and 87900 are not supported in the medical 
record. Specifically, the test panel is a single test with multiple components and is characterized by a single 
unit of service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the 
fact that the test reports multiple individual pathogens and/or targets. The results of susceptibility testing are 
interpreted as S (sensitive), I (intermediate), or R (resistant) followed by the minimum inhibitory concentration 
(MIC) in microgram per milliliter (ug/mL) units. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 87481, 87640, 87652, 87798, 87899, and 87900 billed for date of service November 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae breast cancer 1 and 2 (BRCA1/2) (81433) 
provided June 5, 2023. 

You asked the Plan to pay for the genetic testing. You say that based on the provided information and the 
physician's decision to order the test, you are requesting coverage at this time for the claim. The Plan denied 
your request. The Plan says this service does not meet Medicare criteria. 
 
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 find that CPT code 81433 is not supported in the medical record. Specifically, the Invitae 
BRCA1/2 panel (81433) is not covered by Medicare per the Diagnostics Exchange (DEX). The requested 
genes for the Invitae BRCA1/2 Panel (81433) are already included in the 100 gene panel (81432) which is 
duplicative, not expected to give additional information separate from the approved test. 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 the Invitae breast cancer 1 and 2 (BRCA1/2) (81433) 
provided June 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (27654) provided on May 26, 2023. 
 
You asked the Plan to pay for the surgical services (27654). You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 27654 is not supported in the medical record. Specifically, this procedure was billed 
without a required device code. The billed code is device dependent. Based on this information, we decided 
that Medicare rules for coverage of the surgical services (27654) have not been met. Therefore, we decided that 
the Plan does not have to pay for surgical services (27654) provided on May 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that it is medically necessary. The Plan 
denied your request. The Plan says there is not enough evidence to show that this procedure is as safe and as 
helpful as other standard treatment options. 
 
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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
this request to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
corroborate the use of genicular nerve blocks are as safe and effective as standard treatment modalities. No compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested genicular nerve block is not medically reasonable or 
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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal surgery and bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow 
aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 the bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is not sufficient high-quality evidence to support the benefit of bone marrow aspirate in the setting of spinal fusion surgery. Therefore, the reviewer found that the requested bone 
marrow aspirate is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal surgery and bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64445 and 64447 billed for date of service 
February 2, 2023. 
 
You asked the Plan to pay for procedure codes 64445 and 64447. You say that the nerve block charges were 
performed by the anesthesiologist at the request of the surgeon for post operative pain relief. You say that the 
claim should be reprocessed. The Plan denied your request. The Plan says procedure codes 64445 and 64447 
are included in procedure code 01472 and cannot be separately reimbursed. 
 
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 64445 and 64447 are column II codes to column I code 01472; 
however, 64445 and 64447 were billed with a modifier.  
 
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 codes 64445 and 64447. Our reviewer says that 
procedure codes 64445 and 64447 are not supported as separately identifiable procedures in this case. Our 
reviewer found that the record does not state that the surgeon requested nerve blocks for postoperative pain 
management. Therefore, these procedures are included in anesthesia services and cannot be reported separately.  
 
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 codes 64445 and 64447 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 64445 and 64447 billed for date of service February 2, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve impedimed l-dex testing device. 
 
You asked the Plan to pre-approve impedimed l-dex testing device. You say that it is medically necessary. The 
Plan denied your request. The Plan says it is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve impedimed l-dex testing device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested treatment, impedimed l-dex testing device, has not been 
proven in high level prospective clinical trials to detect or improve treatment of lymphedema. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of impedimed l-dex testing device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve impedimed l-dex testing device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) test (0037U) provided June 
24, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that you ask for review of this appeal with all 
necessary documentation that has been attached and determine that these services are medically necessary. The 
Plan denied your request. The Plan says this service does not meet the NCD medically necessary coverage 
requirements. 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. The records also show that the enrollee has non-small cell lung cancer but does not have 
metastatic, recurrent, relapsed, or refractory cancer. 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 FoundationOne CDx 
(F1CDx) test (0037U) provided June 24, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services billed with code A0998-QL on July 13, 
2022. 
 
You asked the Plan to pay for ambulance services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was 
pronounced dead after the ambulance is called/dispatched but before the ambulance arrives at the scene, 
payment may be made if the provider reports the A0428 (BLS) non-emergency or A0429 (BLS) emergency 
transport code if an emergency response and modifier QL.  
We looked at the file and Medicare rules. The record shows that the enrollee was pronounced dead and the 
service was billed with modifier QL, but the service was billed with code A0998 instead of A0428 or A0429 as 
required. Based on this information, we decided that Medicare rules for coverage of ambulance services have 
not been met. Therefore, we decided that the Plan does not have to pay for ambulance services billed with code 
A0998-QL on July 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography, transthoracic (TTE) with doppler 
complete (93306) provided on May 9, 2023. 
 
You asked the Plan to pay for TTE with doppler complete. You say that medical records submitted support 
code 93306 and should be paid. The Plan denied your request. The Plan says the submitted medical records do 
not indicate that echocardiography, transthoracic (TTE) (93306), real-time with image documentation (2D), 
includes M-mode recording was performed. The Plan says that the documentation does not contain all elements 
for a complete echocardiogram; therefore, the CPT code 93306 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 93306 is echocardiography, transthoracic (TTE), real-
time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral 
doppler echocardiography, and with color flow doppler echocardiography.  

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 TTE with doppler complete. Our reviewer says that the 
medical records provided does not include sufficient documentation to verify a complete echocardiography 
transthoracic procedure has been performed. CPT code 93306 requires real-time imaging and documentation of 
2D and M-mode images of the bilateral atria and ventricles; spectral and color doppler over the aortic, mitral, 
tricuspid, pulmonic valves; and evaluation of the pericardium and adjacent portions of the aorta. This 
documentation was not found in the medical record and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE with doppler complete have not been met. Therefore, we decided that the 
Plan does not have to pay for the echocardiography, transthoracic (TTE) with doppler complete (93306) 
provided on May 9, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from April 21, 2023, to May 20, 2023 
 You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable. The Plan denied your request. The Plan says criteria for the SNF admission had not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the received records, there is no evidence that the enrollee required or 
received skilled services for the dates of service in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from April 21, 2023, to May 20, 2023
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel provided February 6, 2023, billed with 
codes 87500-59, 87641-59, 87798 x12, G0452-26, 87491-59, 87496-59, 87511-59, 87529-59, 87532-59, 
87563-59, 87591-59, 87661-59, 87481-59, 87651-59, 87653-59. 
 
You asked the Plan to pay for the laboratory testing. You say that you find that this denial was made in error, 
and you ask that this decision be reversed, and reimbursement be made for the services. The Plan denied your 
request. The Plan says this service does not meet the Medicare criteria. 
 
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 looked at the file and Medicare rules. This was panel testing 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 testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel provided 
February 6, 2023, billed with codes 87500-59, 87641-59, 87798 x12, G0452-26, 87491-59, 87496-59, 87511-
59, 87529-59, 87532-59, 87563-59, 87591-59, 87661-59, 87481-59, 87651-59, 87653-59.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae breast cancer 1 and 2 (BRCA1/2) (81433) 
provided May 26, 2023.  
 
You asked the Plan to pay for the genetic testing. You say that based on the provided information and the 
physician's decision to order the test, you are requesting coverage at this time for the clam The Plan denied 
your request. The Plan says this service does not meet Medicare criteria 
 
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 find that CPT code 81433 is not supported in the medical record. Specifically, the Invitae 
BRCA1/2 panel (81433) is not covered by Medicare per the Diagnostics Exchange (DEX). The requested 
genes for the Invitae BRCA1/2 Panel (81433) are already included in the 100 gene panel (81432) which is 
duplicative, not expected to give additional information separate from the approved test.  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 the Invitae breast cancer 1 and 2 (BRCA1/2) (81433) 
provided May 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit billed under (Claim A).

You asked the Plan to pay Claim A. The Plan denied your request. The Plan says the Medicare billing criteria
were not met. Maximus overturned the Plans denial. The Plan requested a reopen and provided additional
information. The Plan demonstrated that this claim denied because they previously paid this service on Claim
B. The NPI website shows that both billing providers practice under same the Nurse Practitioner Family
Taxonomy. In addition, both providers belong to the same provider group.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that if more than one
service is provided on the same day to the same patient by the same physician or more than one physician in
the same specialty in the same group, only one service may be reported unless the services are for unrelated
problems.

Based on the documentation provided, this Claim A cannot be paid as billed due to the physician group
relationship between the two providers and the omission of the modifier required to identify this as a separate
and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have
to pay for an office provided to the enrollee, and billed under Claim A.