Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the member is receiving appropriate in-patient acute 
care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting.  The health plan has approved ongoing care 
in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to the enrollee's complex medical 
needs a LTACH level of care would provide them the with the medical care required.  The Plan denied your 
request. The Plan says the enrollee can continue to receive their care in the current hospital.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS3D testing (88361-59 x 4, 88312-XE, 88305-XE 
and 88112-XE) provided on August 16, 2022.  
 
You asked the Plan to pay for the laboratory services. You say that  this is appropriate testing. The Plan denied 
your request. The Plan says  this testing is not appropriate. 
 
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 provided records in this case do not document the patient had known or suspected 
BE. Records in this case consist of the test order form and test results with a diagnosis of gastro-esophageal 
reflux disease without esophagitis (K21.9). No other information was provided to support the need for the 
WATS3D sampling and how it would aid in the diagnosis or treatment of the patient's condition or to improve 
the function of a malformed body member and that it was furnished in a setting appropriate to the patient's 
medical needs and condition as required by Medicare rules. 
 
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 the WATS3D testing (88361-59 x 4, 88312-XE, 88305-XE and 88112-XE) provided 
on August 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on October 17, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home 
health services under a plan of treatment. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required TOB 
032x code. 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 the home health services rendered on 
October 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81479, 81226, 81225) provided on 
August 29, 2022. 
 You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary and 
ordered by the enrollee's doctor.  The Plan denied your request. The Plan says the pharmacogenetics testing is 
not considered medically necessary for this enrollee. 
 
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 physician 
reviewer found the enrollee has tried and failed medical therapy with Lexapro, Zoloft, and Wellbutrin. The 
enrollee is presently maintained on medical therapy with Ritalin. There was no specific clinical rationale for the 
requested pharmaogenetic testing. The review has determined that the phamacogenetics testing at issue was not 
medically necessary in accordance with the LCD rules. 
 
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 the laboratory services (81479, 81226, 81225) provided on August 29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81345, 0089U) provided on January 14, 2022. 
 
You asked the Plan to pay for the laboratory services . You say that based on the information provided along 
with supporting documentation that clearly shows medical necessity per Medicare criteria  The Plan denied 
your request. The Plan says that this service does not meet the requirements based on the details given. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case.  Our physician 
reviewer found the analysis of a large, United States registry study demonstrated greater than 99 percent 
negative predictive value in PLA-negative, melanocytic lesions in up to 12 months of follow-up, suggesting 
clinical utility to reduce unnecessary biopsies for melanoma diagnosis. Meaning a negative test avoids a 
biopsy. The service was reasonable and 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 laboratory services have been met. Therefore, we decided that the Plan has 
to pay for the laboratory services (81345, 0089U) provided on January 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneDose Genetic Response Report (comprehensive 
hereditary pharmacogenomic testing) and the Hereditary Genetic Cardiac Test panel (81225, 81226, 81227, 
81231, 81232, 82140, 81241, 81291, 81306, 81328, 81335, 81238) provided on December 11, 2022.  
You asked the Plan to pay for the testing. You say that the medical records have been attached to this appeal. 
Please have a look at the attachment and reconsider the charges which were previously denied. The Plan denied 
your request. The Plan says the medical necessary criteria has not been met for Medicare coverage.  
 
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 testing. Our physician reviewer found 
there is no documentation from the provider documenting the drugs being considered for use and no 
documentation to how the results will impact treatment. The review has determined that the medical records 
provided did not meet the requirements listed in the LCD for Medicare coverage. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the GeneDose Genetic Response Report (comprehensive hereditary pharmacogenomic testing) and 
the Hereditary Genetic Cardiac Test panel (81225, 81226, 81227, 81231, 81232, 82140, 81241, 81291, 81306, 
81328, 81335, 81238) provided on December 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 7, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that medical records were submitted to support 
medical necessity.  The Plan denied your request. The Plan says more information is needed. 
 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 physician 
reviewer found provided medical records in this case do not document the enrollee has a condition where 
clinical evaluation has determined the need for a medication that has a known gene-drug interaction(s) for 
which the test results would directly impact the drug management of the enrollee's condition. Provided medical 
records in this case do not document that this test has clinical utility/validity as of December 7, 2022, for this 
specific enrollee. Provided medical records in this case do not document the enrollee has a condition where 
clinical evaluation has determined the need for a medication that has a known gene-drug interaction(s) for 
which the test results would directly impact the drug management of the enrollee's condition. Provided medical 
records in this case do not document that this test meets evidence standards. 
 
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 the laboratory services provided on December 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 2, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary.  The 
Plan denied your request. The Plan says the pharmacogenomic testing and genetic testing for cardiovascular 
disease were not 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 pay for the laboratory services. Our physician 
reviewer found there was no specific clinical rationale for the obtained laboratory testing. There was no 
documentation of any change in the enrollee's present management. The review has determined that the 
pharmacogenomic testing and genetic testing for cardiovascular disease was not medically necessary in 
accordance with the referenced 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services provided on December 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 14, 2021, to 
January 20, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly. The Plan denied your request. The Plan says  the secondary diagnosis code G93.41 is 
not supported. 
 
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 G93.41 - metabolic encephalopathy. 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 physician reviewer found the Health Plans denial should be upheld. The enrollee presented following a 
syncopal episode. The enrollee was initially found to have a urinary tract infection (UTI) and noted to have 
baseline dementia. The enrollee was secondarily found to have a subtherapeutic digoxin level and 
hypothyroidism, both likely due to poor medication compliance.  There is no evidence that the enrollee had 
altered mental status beyond what is expected from the enrollee's identified diagnoses. The enrollee's diagnoses 
are better ordered as UTI, hypothyroidism, syncope, subtherapeutic digoxin, dementia, medication non-
compliance. The billing of G93.41 is not supported  
 
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 provided on January 14, 2021, to January 20, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that these lab services were medically 
necessary. The Plan denied your request. The Plan says the pharmacogenomics testing and genetic testing for 
cardiovascular disease were not 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 pay for the laboratory services. Our physician 
reviewer found there was no specific clinical rationale for the requested laboratory testing. There was no 
documentation of any specific planned change in the enrollee's present medical therapy. The review indicates 
that the pharmacogenomic testing and the genetic testing for cardiovascular disease was not medically 
necessary in accordance with the LCDs referenced. 
 
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 the laboratory services provided on December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87150 billed for date of service September 1, 
2022. 
 
You asked the Plan to pay for procedure code 87150. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 87150 is bundled into payment for code 87500. 
 
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 87150 
is a column II code to column I code 87500. 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 87150 billed for date of service September 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 for date of service October 6, 2022. 
 
You asked the Plan to pay for procedure code 99239. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the service billed is 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not 
include the time spent providing this service. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99239 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99239 for date of service October 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service November 3, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary.  The Plan 
denied your request. The Plan says that the claim is missing the required unique identifier. 
 
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. 
 
We looked at the file and the rules. The Local Coverage Determination and Article (L36807 and A57772) the 
Plan used in their decision to deny services is not binding in this case. The rules do not have Medicare Part B 
jurisdiction in Pennsylvania, where the services were provided. The applicable Local Coverage Article, 
A58917, does not indicate that a DEX Z code is required for billing. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for the lab testing billed for date of service November 3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 provided on date of service December 
7, 2022. You asked the Plan to pay for procedure code 99153. You say that supporting documentation was provided.  
The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. The claim shows that the services were provided in 
an off-campus outpatient hospital facility. There is no separate payment to the physician for CPT code 99153 
when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for procedure 
code 99153 provided on date of service December 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 87634-59 billed for date of service October 17, 2022. 
 
You asked the Plan to pay for code 87634-59. You say that your organization was required to perform these lab 
services on COVID-19 positive patients. The Plan denied your request. The Plan says code 87634-59 is not 
supported. This code is included in code 87798. The documents do not support that the procedure or service 
was distinct or independent from other services performed, so the use of the 59 modifier is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 87634-59 Our reviewer says that code 
87634-59 is not supported by the medical record. Our physician reviewer found the record shows that a 
respiratory virus panel was performed with multiple respiratory targets. There is a more specific code to report 
this panel. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87634-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 87634-59 billed for date of service October 17, 2022.