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

 
We decided that the Plan does not have to pay for four units of procedure code 87481 rendered on February 23, 
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 documentation does not support that four units were provided.  
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 to pay for is "Infectious agent detection by nucleic acid 
(DNA or RNA); Candida species, amplified probe technique." 
 
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 four units of procedure code 
87481 were rendered on February 23, 2023. The records do support that the additional units were rendered; 
however, the records do not support that the additional services were reasonable or necessary as the 
justification for using more than 3 probes were not explained or justified by the prescribing physician. 
 
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 four units of procedure code 87481 rendered on February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0242U) provided on January 23, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not 
support the billed date of service. 
 
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 payment for CPT code 0242U is not supported in the medical record. Specifically, the records 
show that the specimen was collected on January 16, 2023, and not the billed date of service. As such, the 
records do not support code 0242U for the billed date of service. 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 lab services (0242U) provided on January 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, 87798 and 
87801 billed for date of service February 7, 2023. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, 87798 and 87801. You say that 
these services were necessary and are supported as billed. The Plan denied your request. The Plan says these 
services are not supported in the medical record. 
 
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 codes 87150, 87481, 87641, 87653 and 87798 are column II codes to 
column I codes 87500 and/or 87801; however, 87150, 87481, 87641, 87653 and 87798 were each billed with a 
modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87150, 87481, 87641, 87653, 87798 and 
87801. Our reviewer says that these codes are not supported. Our reviewer found three units of 87801 are not 
supported. The description for this test indicates multiple organisms, it should not be reported with multiple 
units in this case. In addition, the records do not support that codes 87150, 87481, 87641, 87653 and 87798 
were unusual and non-overlapping with the primary procedures. The use of modifier XU to bypass the NCCI 
edit is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87641, 87653, 87798 and 87801 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 
87653, 87798 and 87801 billed for date of service February 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 12, 2022, billed 
with codes 87471, 87481, 87500, 87551, 87640, 87641, 87651, 87653, and 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 a 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 
December 12, 2022, billed with codes 87471, 87481, 87500, 87551, 87640, 87641, 87651, 87653, and 87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27236 for date of service January 2, 2023. 
 
You asked the Plan to pay for procedure code 27236. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 13, 2023. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 27236 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 27236 for date of service January 
2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro Motion G myoelectric upper limb orthosis. 
 
You asked the Plan to pre-approve MyoPro device. You say that this represents the enrollee's best opportunity 
for regaining meaningful use of the limb. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MyoPro device. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MyoPro device is not the standard of care for the enrollee's condition nor is it in widespread 
use for the enrollee's condition. There is insufficient evidence in the medical literature that the MyoPro orthosis 
will improve long-term outcomes for the enrollee.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve MyoPro Motion G myoelectric upper limb orthosis.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on April 27, 2022. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that you were not able to 
stand due to weight bearing concerns and could not be picked up physically and put into a car. You also say 
that you had to lay down for transportation.  The Plan denied your request. The Plan says the documentation 
does not support the non-emergent transportation services. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service and ground mileage. 
Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
transportation via ambulance to your orthopedic appointment was not medically necessary. You were not 
bedbound, as evidenced by your ability to walk with a walker. You did not require the expertise of trained 
personnel or the equipment available only on an ambulance in order to effectuate a safe transport.  
Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) 
without endangering the enrollee's condition. A prudent layperson would not believe that immediate medical 
attention was required for someone who was attending a scheduled follow-up appointment. 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 ambulance service and ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 powered pressure-relieving support surface 
(E0277).  
 
You asked the Plan to pre-approve a group 2 powered pressure-relieving support surface (E0277). You say that 
the requested group 2 powered pressure-relieving support surface (E0277) is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested group 2 powered 
pressure-relieving support surface (E0277).  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a group 2 powered pressure-relieving 
support surface (E0277). Our reviewer says that the enrollee does not meet criteria for the requested group 2 
powered pressure-relieving support surface (E0277).  Our physician reviewer found the enrollee has limited 
mobility due to his medical condition. The documentation doesnt support that he has multiple stage 2 pressure 
ulcers located on the trunk or pelvis and has failed to improve in the previous month with conservative 
treatment with a comprehensive ulcer treatment program or a myocutaneous flap or skin graft. The requested 
pressure reducing support surface is not 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 a group 2 powered pressure-relieving support surface (E0277) have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a group 2 powered pressure-relieving 
support surface (E0277).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 28, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the medical records 
submitted do not include a physician order or laboratory requisition for the billed test. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition for the billed testing. 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 the 
lab services provided on February 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36415 and 82310 billed for January 26, 
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 procedure codes 36415 and 82310 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 36415 is collection of venous blood by venipuncture. The 
definition of code 82310 is total assay of calcium. 
 
We find that CPT codes 36415 and 82310 are not supported in the medical record. Specifically, the submitted 
medical records do not match the enrollee's date of birth and therefore cannot be validated. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 36415 and 82310 billed for January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for February 28, 
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 procedure codes 96365 and 96366 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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). 
 We find that CPT code 96365 and 96366 is not supported in the medical record. Specifically, the records show 
that outpatient intravenous insulin treatment (OIVIT) was performed and there is a more appropriate code for 
these services. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365 and 96366 
billed for February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 00811) rendered on 
April 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 Current Procedural Terminology (CPT) code 00811 AA (572 units) 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. 
 
In this case, the CPT Code Manual definition of code 00811 is "Anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; not otherwise specified." 
 
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 based on the medical records 
provided there is no documentation that CPT 00811-AA (572 units) were rendered in this case. Provided 
records in this case document 32 minutes of anesthesia time for the colonoscopy on April 6, 2023; 572 units of 
CPT 00811 are not supported. 
 
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 anesthesia services (procedure code 00811) rendered on April 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires hands on assistance for 
activities of daily living, bed mobility, transfers and ambulation. The Plan denied your request. The Plan says 
an IRF admission 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower level of care. 
 
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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 72192 rendered on October 27, 
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 was no specific rationale for why the extra services needed to be rendered. 
 
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 72192 is "Computed tomography, pelvis; without 
contrast material." 
 
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 only one unit of CPT 72192 is 
supported in the records for this date of service. 
 
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 72192 rendered on October 27, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the radiology service on May 1, 2023, coded as 73564-26. 
 
You asked the Plan to pay for the radiology service. You say that the radiology service should be paid because 
it is supported by the documentation. The Plan denied your request. The Plan says that the radiology service 
should be considered a review of the findings payable through the evaluation and management code, not 
separately payable. 
 
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. The Plan states that per the American Medical Association (AMA), the review 
or reread of radiology procedures is considered part of the evaluation and management service and should not 
be reported separately. The Plan has not provided evidence that payment was made to another provider for the 
professional component of the radiology service, which means that there is no evidence that this was, in fact, a 
review or reread of the imaging. The Plan also cites the Centers for Medicare Services National Correct Coding 
Initiative regarding procedures with a global surgery indicator of XXX, which does not apply to the code being 
appealed. As such, we find that the Plan has not substantiated the denial of payment for this service. Therefore, 
we decided that the Plan has to pay for the radiology service on May 1, 2023, coded as 73564-26.  
 
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 the services (J3490) provided on February 24, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code can only be 
billed as one 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. 
 
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 J3490 is 
not supported by the records provided. Our reviewer found that the medical record does not include sufficient 
documentation to confirm an unclassified drug. The procedure describes hydromorphone which has an 
assigned procedure code. In this case, this procedure code and number of units cannot be verified. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (J3490) provided on February 24, 2023.