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

 
We decided that the Plan does not have to pre-approve the oncology services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the oncology services. You say that you are requesting reconsideration of 
the denied services. The Plan denied your request. The Plan says the service was not approved. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the oncology services to be provided by an OON provider.
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 you say that you disagree with the denial 
for the admission to LTACH. The Plan denied your request. The Plan says these services are not medically 
necessary. 
 
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 can continue in current setting until stable enough to be discharged to a 
lower level of care facility. These needs do not require the intensity of specialized nursing care or intensive 
therapy offered at an LTACH. The enrollee's needs are currently being met at current location. 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 genetic testing provided on January 27, 2023, billed with 
codes 87641, 87798, 87481, 87653, and 87640. 
 
You asked the Plan to pay for the testing billed. You say that the documentation supports the billing. 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. The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel was not billed with a single code as required. Based on this information, we decided that Medicare 
rules for coverage of the testing billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the genetic testing provided on January 27, 2023, billed with codes 87641, 87798, 87481, 87653, and 
87640.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the services (29824) provided on April 26, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that code 29824 is not 
separately payable. 
 
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 29824 is "Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface 
(Mumford 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 use of code 29824 is 
supported by the records provided. Our reviewer found that the record clearly states that a distal claviculectomy 
was performed. There are no NCCI or CPT rules that bundle this procedure with the other procedures 
performed. For coding purposes, code 29824 is not included in code 29827. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the services (29824) provided on April 26, 2023.  
 
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 ophthalmological services provided on July 24, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for ophthalmological services. You say that you are requesting reconsideration for 
the denied claim. The Plan denied your request. The Plan says this provider is out-of-network, and the services 
could be performed in-network. 
 
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 ophthalmological services provided on July 24, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 24, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided July 12, 2023, through July 
19, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be reprocessed. The Plan denied your 
request. The Plan says they only cover manual manipulation of the spine too correct subluxation. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our physician reviewer found 
the record indicates that the enrollee has thoracic and lumbar pain. The records provided do not document the 
presence of subluxation either by physical examination or radiographic images. The elements of the coverage 
criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for chiropractic services provided July 12, 2023, through July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 11, 2023, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81272. 
 
You asked the Plan to pay for the genetic testing billed. You say that this 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. This was an NGS panel that was not billed with a single panel 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 
April 11, 2023, billed with codes 81162, 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 
81272.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 2, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 24, 2023 to June 22, 
2023. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. 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 May 24, 2023. The NOA was not received by the Plan until July 17, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided on May 
24, 2023 to June 22, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies for a continuous glucose monitor (CGM) device 
(A4239) provided on June 2, 2023. 
 
You asked the Plan to pay for CGM supplies. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that E10.65 has an Excludes1 note in relation to E11.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
supplies for a continuous glucose monitor (CGM) device (A4239) provided on June 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 for date of service April 
21, 2023. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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 find that CPT codes 83520 and 87798 are not supported in the medical record. Specifically, these codes 
represent a not otherwise specified code. However, a complete description of the not otherwise specified codes 
was not included. The claim /order/lab requisition must include what laboratory test(s) were ordered/requested 
in order to validate the not otherwise specified code billed. Therefore, the validity and accuracy of the billed 
service cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure codes 83520 and 87798 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 83520 and 87798 for date of service April 21, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a hospitalist visit (99239) provided on April 8, 2022. 
 
You asked the Plan to pay for 99239. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says that the records do not support that a discharge day management services of more 
than 30 minutes was 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 99239 is hospital inpatient or observation discharge day management; more than 30 minutes on the date 
of the encounter. 
 
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 99239. Our reviewer says that this code meets criteria for 
payment. Our reviewer found documentation supports a time that the doctor spent with the enrollee and 
discharge planning which totals 45 minutes, supporting code 99239. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99239 have been met. Therefore, we decided that the Plan has to pay for a 
hospitalist visit (99239) provided on April 8, 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 lab services provided on January 30, 2023. 
 
You asked the Plan to pay for the lab services. You say that these lab services are covered by Medicare. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services provided on January 30, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is at a high risk for a poor 
outcome if discharged to a lower level of care. The Plan denied your request. The Plan says the records do not 
show that it is medically necessary for the enrollee to be in an LTACH in place of an acute care 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 that the enrollee has not completed the acute hospital course and is medically 
unstable for transfer due to persistent fevers and new deep vein thrombosis. There is no documentation that the 
enrollee is capable of being weaned at this time. There is no documentation indicating medical necessity for admission to an LTACH. 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 Plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished 
safely and effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor supplies (A4239) provided on 
February 17, 2023. 
 
You asked the Plan to pay for continuous glucose monitor supplies. You say that this service was medically 
necessary. The Plan denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that billing more than one (1) unit per thirty (30) days 
of code A4238 or A4239 will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Another unit of this code was already on paid on February 24, 2023. 
Only one unit is allowed every 30 days. Based on this information, we decided that Medicare rules for 
coverage of continuous glucose monitor supplies have not been met. Therefore, we decided that the Plan does 
not have to pay for continuous glucose monitor supplies (A4239) provided on February 17, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 will require continued medical 
management of comorbidities and polypharmacy needs, as well as daily physical and occupational therapies to 
address their deficits. You also say the services required by the enrollee cannot be safely met with home health 
services or skilled nursing facility care at this time. The Plan denied your request. The Plan says admission to 
an IRF is not medically necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for IRF 
admission. Indeed, this enrollees condition is in fact very complex and fragile, and there is every reason to 
expect that they will participate in and benefit from services to include at minimum physical therapy, 
occupational therapy (with emphasis on pre-prosthetic rehabilitation), physician oversight of polypharmacy, 
and case manager coordination of any additional services and outpatient appointments that might be needed to 
make a sustainable return home, as well as avoid further preventable readmissions to the acute hospital. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 Guardant360 testing provided on February 2, 2023. 
 
You asked the Plan to pay for molecular diagnostic test. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing was not billed with the appropriate DEX Z-Code as 
required by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic tests must be billed with the 
appropriate DEX Z-Code identifier adjacent to the procedure code in the comment/narrative field.  
 We looked at the file and Medicare rules. This testing was not billed with the appropriate DEX Z-Code 
identifier as required by Medicare. Based on this information, we decided that Medicare rules for coverage of 
molecular diagnostic test have not been met. Therefore, we decided that the Plan does not have to pay for 
Guardant360 testing provided on February 2, 2023.