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

 
We decided that the Plan does not have to pay for Resolve mdx for urinary tract infection (UTI) provided on 
June 21, 2023, and billed with codes 87481, 87500, 87798, 87640, and 87652. 
 
You asked the Plan to pay for Resolve mdx for UTI. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says the unbundling of lab codes for polymerase chain reaction (PCR) panel 
testing is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for Resolve mdx for urinary tract infection (UTI) provided on June 21, 2023, and 
billed with codes 87481, 87500, 87798, 87640, and 87652.
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 needs to get strength back their in lower 
extremities. The Plan denied your request. The Plan says that the enrollee's needs can be met at an alternate 
level of care.  
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable x-ray services described by codes R0070, 
Q0092, and 73650-TC-LT billed on date of service April 26, 2023, and April 27, 2023. 
 
You asked the Plan to pay for the portable x-ray services. You say that the portable x-ray services should be 
paid as billed because they were originally paid prior to recoupment, and they are supported in the 
documentation. The Plan denied your request. The Plan says the portable x-ray services are denied because 
they were performed while the enrollee was in a covered SNF stay, so they are included in the SNF PPS 
(Prospective Payment System) rate. 
 The Plan must follow Medicare rules. Medicare rules say that when a SNF resident receives a portable x-ray 
service, only the service's professional component is a separately billable physican service under Part B.  
 
We looked at the file and Medicare rules. We confirmed that codes R0070, defined as transportation of portable 
x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen, and 
Q0092, defined as set-up portable x-ray equipment, have a professional component (PC)/technical component 
(TC) flag of 3. This indicator identifies stand-alone codes that describe the technical component (for example, 
staff and equipment costs) of selected diagnostic tests only. We confirmed that in this case, code 73650 was 
billed with modifier -TC, also indicating the technical component only. According to Medicare rules, when an 
enrollee receives a portable x-ray service during the course of a Part A covered SNF stay, the technical 
component of a procedure, including any associated transportation and set up costs, must be included on the 
SNF's Part A bill for the enrollee's covered stay. The technical component is not separately billable by the 
physican under Part B. Based on this information, we decided that Medicare rules for coverage of the portable 
x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the portable x-
ray services described by codes R0070, Q0092, and 73650-TC-LT billed on date of service April 26, 2023, and 
April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99204) rendered on January 
31, 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 99204 (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 that the enrollee was seen in an office 
visit on 1/31/23 for an evaluation related to symptoms of chest pain related to a pacemaker. The documentation 
from this date includes an appropriate history and examination. The plan included referral to an 
electrophysiologist to evaluate pacer lead voltage and possible fracture lead or other abnormality. Vitals were 
stable. There was no support for a moderate level of medical decision-making or the encounter lasting 45-59 
minutes as required to justify the CPT 99204.  
 
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 an office visit (procedure code 99204) rendered on January 31, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 10, 2023, to May 09, 
2023. 
 
You asked the Plan to pay for psychotherapy. You say that the in-network provider was booked solid and had 
no idea when they could schedule you, so you found a therapist who was able to see you. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided 
on January 10, 2023, to May 09, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
on June 26, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that you disagree with this determination and 
request a redetermination of the denial. 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. 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 unlisted molecular pathology procedure 
(81479) provided on June 26, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on August 6, 2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the presenting problem was not a high risk or immediate threat to life for physiological function. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making." 
 
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 a medically appropriate history 
and physical was performed; however, the documentation does not support medical decision 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 emergency room services (procedure code 99284) rendered on August 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231 billed for date of service June 15, 
2023.  
 
You asked the Plan to pay for procedure code 99231. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99231 is bundled into payment for code 
99233. 
 
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 99231 is a column two code to column one code 99233 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 99231 billed for date of service June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CMNext testing (81439). 
 
You asked the Plan to pre-approve CMNext testing. You say that this test is medically necessary. The Plan 
denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of CMNext testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve CMNext testing (81439).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 hours of neuropsychological testing. 
 
You asked the Plan to pre-approve 4 hours of neuropsychological testing. You say that 4 hours of 
neuropsychological testing is medically necessary. The Plan denied your request. The Plan says 4 hours of 
neuropsychological testing is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is covered when the 
criteria listed in the Medicare rules section of this decision 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 4 hours of neuropsychological testing. 
Our reviewer says that the requested 4 hours of neuropsychological testing is not considered medically 
reasonable and necessary in this case. Our physician reviewer found typically, psychological testing will 
require from four (4) to six (6) hours to perform, including administration, scoring and interpretation. 
Supporting documentation in the medical record must be present to justify greater than 8 hours per patient per 
evaluation. If the testing is done over several days, the testing time should be combined and reported all on the 
last date of service. If the testing time exceeds eight (8) hours, medical necessity for extended time should be 
documented. Medical records may be requested. The provided records in this case do not document any 
medical necessity for the extended testing time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 hours of neuropsychological testing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 4 hours of neuropsychological testing.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiography and duplex scan provided on 
June 26, 2023. 
 
You asked the Plan to pay for an echocardiography and duplex scan. You say that you should not be 
responsible for the facility fee since it was performed in a provider office. 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. Your 
contract with the Plan says that there is a $850 deductible which applies to outpatient hospital services, 
diagnostic procedures and tests.  
 
The item or service you asked the Plan to pay for falls within the outpatient hospital services, diagnostic 
procedures and tests benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $850 deductible which applies to outpatient hospital services, diagnostic procedures and 
tests. This cost sharing is a contractual obligation that had not been met at the time an echocardiography and duplex scan was received on June 26, 2023. Therefore, we decided that the Plan does not have to pay for an 
echocardiography and duplex scan provided on June 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 16 units of procedure code 88341 performed on June 21, 
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 there was no specific rationale as required by the policy as to why additional units needed to be 
performed. 
 
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 88341 is "Immunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
address the rationale for additional units of immunohistochemistry or immunocytochemistry. 
 
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 16 units of procedure code 88341 performed on June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (G0483, 80307) provided on July 3, 2023. 
 
You asked the Plan to pay for the lab testing. 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. The rules also state that it is not appropriate to 
report more than one (1) presumptive test result per patient per date of service regardless of the number of 
billing providers. 
 
We find that CPT codes G0483 & 80307 are not supported in the medical record. Specifically, code G0483 is a 
column II code to column I code 80307. Additionally, records show that code 80305 was paid already for the 
same date of service. Only one presumptive drug test is payable per date of service. Code 80307 cannot be 
paid. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been 
met. Therefore, we decided that the Plan does not have to pay for lab testing (G0483, 80307) provided on July 
3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with codes 87481, 87500, 
87640, 87651, 87653, and 87798 for date of service August 4, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.   
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services billed with codes 87481, 87500, 87640, 87651, 87653, and 
87798 for date of service August 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 95861 performed on June 17, 
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 there is no separate second study report to support the additional unit.  
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 95861 is "Needle electromyography; 2 extremities with 
or without related paraspinal areas." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee only had 
electromyography (EMG) recording done in two limbs during the course of the procedure. The CPT code billed 
reflects provision of EMG in 2 limbs. In such a setting only one unit of this CPT code should have been 
submitted. Testing in 4 limbs is otherwise reflected in the use of a different code.    
 
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 two units of procedure code 95861 performed on June 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service July 25, 
2023.  
 
You asked the Plan to pay for procedure code 76641. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service July 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy rendered on July 31, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that ultraviolet cabinets are covered for selected patients 
with generalized intractable psoriasis. 
 
We looked at the file and Medicare rules. The file shows that the enrollee does not have a diagnosis of 
intractable psoriasis. 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 ultraviolet (UV) light 
therapy rendered on July 31, 2023.