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

 
We decided that the Plan does not have to pay for procedure code 87798 billed for April 11, 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 code 87798 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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, there is no lab report to 
support the services were performed for the date of service at issue. 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 code 87798 billed for April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Life 2000 portable mobile ventilator (E0466). 
 
You asked the Plan to pre-approve the Life 2000 portable mobile ventilator. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Life 2000 portable mobile 
ventilator. Our reviewer says that the enrollee does not need this item. Our physician reviewer found the 
enrollee's documentation and data provided did not support the need for home ventilator. 
 
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 Life 2000 portable mobile ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Life 2000 portable mobile ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99219 billed for date of service September 14, 2021. 
 
You asked the Plan to pay for code 99219. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed this code with an incorrect Place of Service 
(POS). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and POS code.  
In this case, the CPT Code Manual definition of code 99219 is Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of moderate complexity.  
 
By definition, code 99219 is an observation service. Observation is an outpatient status. However, you billed 
POS code 21, indicating that the patient was an inpatient. This is not correct.  This code should have been 
billed with POS 22, reflecting the observation service occurred in an outpatient hospital setting. 
 
Based on this information, we decided that Medicare rules for coverage of code 99219 have not been met. 
Therefore, we decided that the Plan does not have to pay for code 99219 billed for date of service September 
14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 24, 2022, billed with 
codes 81191, 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81309, 81317 and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have billed the services at issue 
correctly. 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 
March 24, 2022, billed with codes 81191, 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 
81309, 81317 and 81401.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 19, 2023. 
 
You asked the Plan to pay for the genetic testing billed. 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 
January 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infectious agent detection panel provided on 
April 28, 2022, billed with codes 87801, 87653, 87798, and 87481. 
 
You asked the Plan to pay for the testing panel. You say that this was billed correctly for medically necessary 
services.  The Plan denied your request. The Plan says this was not billed correctly based on the Local 
Coverage Article (LCA) A58726. 
 
Please note: We reviewed the file and the LCA cited and find that the services were performed in the State of 
Texas. The LCA cited by the Plan is not applicable in this jurisdiction. As such, we did not use this in our 
decision.  
The Plan must follow Medicare rules. Medicare rules say that a single laboratory procedure shall be reported as 
one unit of service whether it generates one or multiple results.  
 
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 urinary tract infectious agent detection panel provided on April 28, 2022, 
billed with codes 87801, 87653, 87798, and 87481.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive PGX hereditary pharmacogenomic 
testing and the comprehensive cardio hereditary genetic testing provided May 11, 2023, billed with codes 
81225, 81226, 81227-59, 81231-59, 81232-59, 81240-59, 81241-59, 81291- 59, 81306-59, 81328-59, 81335-
59, 81479-GY 59. 
 
You asked the Plan to pay for the genetic testing. You say that you have attached additional documents to 
support the claim.  The Plan denied your request. The Plan says the records do not support that the services 
were 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 pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the denial of the comprehensive hereditary pharmacogenomic testing 
and the hereditary genetic cardiac testing is appropriate given the clinical scenario and CMS guidance 
presented in the LCD's above. The enrollee does not meet the established criteria for coverage. The requested tests are not medically necessary and reasonable. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the comprehensive PGX hereditary pharmacogenomic testing and the comprehensive cardio 
hereditary genetic testing provided May 11, 2023, billed with codes 81225, 81226, 81227-59, 81231-59, 
81232-59, 81240-59, 81241-59, 81291- 59, 81306-59, 81328-59, 81335-59, 81479-GY 59.
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 this care to return to prior level of 
function. The Plan denied your request. The Plan says medical records do not support the need for an IRF 
admission and, the enrollee needs can be provided at another setting.  
 
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 the complexity of the enrollee's medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. The enrollee's rehabilitation needs 
can be safely provided in an alternate 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99205 billed for date of service May 19, 
2023.  
 
You asked the Plan to pay for procedure code 99205. You say that this claim should be paid. 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 99205 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Please note that one unit of code 99205 was already paid for this date of service on 
August 29, 2023. Based on this information, we decided that Medicare rules for coverage of procedure code 
99205 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99205 
billed for date of service May 19, 2023.
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval.  
 
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 the complexity of the enrollees nursing, medical, and rehabilitation needs does not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement. However, the documentation does not support that the enrollee would meet criteria for 
admission to an IRF.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintaintheir functional status.  The enrollee can receive further services 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 inpatient rehabilitation facility (IRF) admission and services.
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 based on noted impairments and functional 
limitations, the enrollee is potentially unsafe to discharge to their prior living situation. You also say that upon 
discharge the enrollee could benefit from intensive daily therapy to escalate recovery. 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation 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, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF.  There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain their functional 
status.  The enrollee can receive further services 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 inpatient rehabilitation facility (IRF) admission and services.
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 you need to go into a rehabilitation facility as soon 
as possible. The Plan denied your request. The Plan says the IRF services are not all met so admission cannot 
be covered.  
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, at an intensive rehabilitation therapy program. You continue to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement however, the documentation 
doesnt support that you would meet criteria for admission to an acute inpatient rehabilitation facility.  There is 
no indication that you would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain their 
functional status.  You can receive further services 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) (95957) 
provided on June 14, 2023. 
 
You asked the Plan to pay for the EEG. You say that medical records submitted support code 95957 and should 
be paid. The Plan denied your request. The Plan says the medical record does not support the performance of 
digital analysis or was extra technician time and physician work documented. Therefore, code 95957 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 95957 is digital analysis of electroencephalogram (EEG). 
 
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 EEG. Our reviewer found that the medical record does 
not include sufficient documentation to verify the service provided. The record does not support that an EEG 
was performed, as well as digital analysis of the EEG. Therefore, code 95957 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 the EEG have not been met. Therefore, we decided that the Plan does not have 
to pay for digital analysis of electroencephalogram (EEG) (95957) provided on June 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the breast surgery to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the breast surgery. You say that you would like the enrollee's surgery 
approved at an in-network benefit level. The Plan denied your request. The Plan says the services are not 
authorized because the provider is out-of-network. The enrollee may continue to seek care from this provider 
using the out-of-network benefit at a higher out of pocket cost. 
 
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 breast surgery to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary and 
supported by strong science. The Plan denied your request. The Plan says this is considered experimental and 
therefore is not covered. 
 
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 the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not indicate a clear cause for the enrollee's 
pain. Therefore, the reviewer found that the requested Intracept procedure is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628).