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

 
We decided that the Plan does not have to pay for procedure code 36215 rendered on April 4, 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 Current Procedural Terminology (CPT) code 36215 (1 Unit) 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. 
 
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 CPT code 36215 is not supported. 
This procedure is part of the description of approved code CPT 36902 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 36215 rendered on April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on March 6, 2023. 
 
You asked the Plan to pay for 99214. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the record does not support moderate level of decision-making or the total time 
required for the code 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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, the record does not support a duration of 30 to 39 minutes as is required for selection of this code. Based on this information, we decided that 
Medicare rules for coverage of 99214 have not been met. Therefore, we decided that the Plan does not have to 
pay for an office visit (99214) provided on March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the preventive physical examination 
provided by an in-network provider on April 19, 2023. 
 
You asked the Plan to waive the cost sharing for the preventive physical examination. You say that you went to 
see your primary care physician. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $110.11 copayment for the preventive physical examination because the Plan is 
only holding you responsible for this amount which is less than the $200 copayment. This item/service falls 
within the outpatient hospital services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for 
the preventive physical examination provided by an in-network provider on April 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 21, 2022, billed 
with codes 87502 and 87634. You asked the Plan to pay for the genetic testing billed. 

You say that the testing was medically necessary. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. The respiratory panel test was not billed with a single code as 
required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 21, 2022, billed with codes 87502 and 87634.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve intravascular lithotripsy. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says that more research is needed to show the safety and effectiveness of this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 procedure. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation supports the medical necessity of the treatment in question. There is 
documentation of disabling claudication and intermittent rest pain on the left. The enrollee is status post 
diagnostic angiography demonstrating a severely calcified, high-grade, pre-occlusive stenosis of the distal left 
external iliac artery. This will necessitate treatment; however, due to the heavy calcification, there is an 
elevated risk for procedural failure and potentially iliac rupture. The intravascular lithotripsy is designed to 
selectively breakdown the calcium in the wall of the artery to make it more supple and compliant to the planned 
angioplasty stenting.  As this will be expected to improve both the durability and safety of the procedure, it is 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have been met. Therefore, we decided that the Plan has to pre-
approve intravascular lithotripsy.  
 
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 code 87801 (3 units) billed for date of service 
September 9, 2022. 
 
You asked the Plan to pay for three units of code 87801. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says this code is not supported in the medical 
record for the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 three units of code 87801. Our reviewer says 
that the number of units billed for this code is not supported. Our physician reviewer found the description for 
this code includes multiple organisms, and therefore should be reported with one unit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of three units of code 87801 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87801 (3 units) billed for date of service September 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 24, 2022, to 
April 22, 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 24, 2022. The NOA was not received by the Plan. 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 24, 
2022, to April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (96365, 96366) provided on December 5, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed 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. 
 
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 use of codes 96365 
and 96366 is not supported by the records provided. Our reviewer found that the medical record includes an 
outpatient procedure for intravenous insulin treatment (Novolin R). In this case, there is a more specific 
HCPCS code that should be reported for the documented services. 
 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 the services (96365, 96366) provided on December 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99292) provided on March 10, 2023. 
 
You asked the Plan to pay for critical care services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99292 is an additional 30 minutes of critical care time. 
 
We find that CPT code 99292 is not supported in the medical record. Specifically, the records show 60 minutes 
of this service was provided. Code 99291 includes up to 74 minutes of critical care evaluation and management 
time. An additional 30 minutes is not supported. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have to pay 
for critical care services (99292) provided on March 10, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 81450. We decided that the 
Plan does not have to pay for the services described by procedure code(s) G0452.  
 
You asked the Plan to pay for procedure codes 81450 and G0452 billed for date of service March 23, 2023. 
You say that these services were necessary and are supported in the medical record. The Plan says that these 
services were not billed in accordance with Medicare guidelines. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 81450.  
 
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 denied payment for this code, stating that this service was 
not billed with a valid DEX-Z code as required by the Molecular Diagnostics (MolDX) contractor. However, 
the Local Coverage Determination cited by the Plan does not apply to the state where this test was actually 
performed. The state in question does not participate in the MolDX program, and therefore MolDX rules do not 
apply. The Plan has provided no other reason for denial of this service. Therefore, we decided that the Plan has 
to pay for the services described by procedure code(s) 81450.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
G0452. 
 
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 G0452 is a column II code to column I code 81450; however, G0452 
was 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 code G0452. Our reviewer says that this code is 
not supported for separate payment. Our reviewer found that the documentation does not show that this service 
was separate and distinct from the primary procedure. 
 
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 described by procedure code(s) G0452 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
G0452. 
 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 pre-approve negative pressure wound therapy (NPWT) electrical 
pump, stationary or portable (E2402 x1) and wound care set, for negative pressure wound therapy electrical 
pump, includes all supplies and accessories (A6550 x15). 
 
You asked the Plan to pre-approve NPWT pump and supplies. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that NPWT pump and supplies are covered when specific 
criteria are met. 
 
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 NPWT pump and supplies. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the request is not 
medically necessary because the records demonstrate that the wound increased in size from June 6 to July 7 
despite treatment with NWPT. The review has determined that the enrollee does not meet the coverage criteria 
detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of NPWT pump and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve negative pressure wound therapy (NPWT) electrical pump, stationary or 
portable (E2402 x1) and wound care set, for negative pressure wound therapy electrical pump, includes all 
supplies and accessories (A6550 x15).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223, 99233) provided on December 29, 2022, 
and December 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded". The CPT Code Manual definition of code 99233 is 
"Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded". 
 
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 use of codes 99223 
and 99233 is not supported by the records provided. Our reviewer found that for code 99223, there was no 
documentation of a comprehensive history, medical decision making of high complexity or total time spent. 
For code 99233, there was no documented interval history or medical decision making of high complexity. 
 
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 the services (99223, 99233) provided on December 29, 2022, and December 30, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H0035 billed for date of service November 8, 
2022, to December 5, 2022. 
 
You asked the Plan to pay for procedure code H0035. You say that these services were approved by the Plan 
and should be covered. 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 H0035 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H0035 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H0035 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H0035 billed for date of service November 8, 2022, to December 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Gastrointestinal (GI) effects comprehensive stool profile, 
andrenocortex stress profile and cortisol awakening response provided January 3, 2023, to January 17, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these tests were medically necessary to 
evaluate the enrollee's symptoms and guide treatment. The Plan denied your request. The Plan says the tests do 
not meet the medical necessity criteria outlined in the LCD and were ordered by a non- qualified provider.  
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the reviewed documentation indicates that the stool testing was conducted for chronic 
diarrhea, abdominal pain and weight loss (3--pound weight change per documentation). The documentation 
provided did not specify that enrollee had any alarm symptoms such as but not limited to clinically significant 
weight loss (usually defined as greater than 10 pounds) related to diarrhea, bleeding, fevers, family history of 
inflammatory bowel disease, is immunocompromised, colon cancer or travel history to regions with recognized 
specific diarrhea related pathogens. For this enrollee, the stool test ordered assessed for a variety of bacterial, 
viral and ova/parasitic infections, fungal infections etc. The provider did not provide documentation on why 
testing for each of these different items would be medically reasonable based on current literature. There was 
no specific clinical rationale for the Andrenocortex stress profile, Add-on Cortisol Awakening Response. The 
review has determined that the items/services at issue in this case were 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for Gastrointestinal (GI) effects comprehensive stool profile, andrenocortex stress profile 
and cortisol awakening response provided January 3, 2023, to January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that you lost your leg and are in a wheelchair and cannot 
stand on your right foot. The Plan denied your request. The Plan says based on Medicare guidelines, the 
requested service does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that sacroiliac joint denervation (also called 
Radiofrequency Ablation or RFA) is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve 
radiofrequency ablation (RFA).