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

 
We decided that the Plan does not have to pay for procedure code 88291 billed for date of service January 23, 
2023. 
 
You asked the Plan to pay for procedure code 88291. You say that these services were medically necessary and 
are supported in the medical record. The Plan denied your request. The Plan says this code does not accurately 
report the service described in the medical records; another code is more appropriate for these services. 
 
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 88291 is cytogenetics and molecular cytogenetics, 
interpretation and report. 
 
 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 code 88291. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the procedure report describes chromosome analysis, 
which is better reported with a more precise/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 procedure code 88291 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 88291 billed for date of service January 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on February 12, 2023. 
 
You asked the Plan to pay for the testing. 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 testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on February 12, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endovascular repair (34705), open femoral artery 
exposure for delivery of endovascular prosthesis, by groin incision, unilateral (34812) and placement of 
extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for 
endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating 
ulcer, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated 
radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per 
vessel treated (34709). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the services are not medically necessary. Abdominal aortic aneurysm (AAA) repair is not 
indicated in the above individual with a diameter of less than 5.5 centimeters (CM). 
 
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 pre-approve the endovascular repair (34705), open femoral artery exposure for delivery of 
endovascular prosthesis, by groin incision, unilateral (34812) and placement of extension prosthesis(es) distal 
to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal 
abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre-procedure 
sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and 
interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated (34709).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 8, 2022, to 
October 11, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.01, described as 
Acute respiratory failure with hypoxia. We asked our physician reviewer to carefully review the case file and 
apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found the enrollee is an 89-year-old male who presented with chest 
pain. Workup revealed acute pericarditis. Lung examination was initially normal without distress or 
rales/wheezes/rhonchi. The enrollee was given low dose oxygen for symptoms related to the pericardial 
effusion/pericarditis. Throughout the hospital course the patient had continued normal exam except for one 
time with slight wheeze at left base. They did not require high flow oxygen support, Bilevel positive airway 
pressure, or vent support. Therefore, documentation did not sufficiently support J96.01 for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 8, 2022, to October 11, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64629, 64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. 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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found magnetic resonance imaging reports severe L4-5 stenosis. The cause of back pain is 
unclear. 
 
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 the Intracept procedure (64629, 64628).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and related supplies. 
 
You asked the Plan to pre-approve the requested items. You say that conservative therapies have been tried. 
The Plan denied your request. The Plan says the enrollee needs cardiac clearance first.  
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are only covered 
under certain medical indications. 
 
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 requested items. Our physician 
reviewer found that the documentation does not support that the enrollee has failed at least 4 weeks of 
conservative care with a basic lymphedema pump. Additionally, the documentation does not support that the 
enrollee has physical findings consisting of truncal, abdominal or chest edema. 
 
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 requested items have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pneumatic compression device and related supplies.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) service (72197) 
performed on June 27, 2022. 
 
You asked the Plan to pay for the MRI. You say that payment is due for these services. The Plan denied your 
request. The Plan says the car insurance company/primary payer paid an amount which is greater than the 
Plan's allowable. Therefore, no additional payment is necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the MRI have been met. Specifically, 
the provider did not submit a complete explanation of benefits (EOB) from the primary payer which details the 
primary payers allowed amount for these services. It is not clear whether the amount paid by the primary payer 
($960.61) is their full allowed cost or whether the provider is required to accept that amount as full payment. 
The Medicare-allowed cost of this MRI is $105.16. If the amount paid by the primary payer is in fact their full 
allowed amount, then we would follow formula 3 to calculate the Medicare secondary payment amount. In this 
case, because the primary payers allowable charge is higher than the Medicare allowable, and the amount 
actually paid by the primary payer appears to be the full allowable, this would mean that the health plan is 
responsible for $0 payment. The appellant has not submitted sufficient information to support that additional 
payment is due in this case. Therefore, we decided that the Plan does not have to pay for the magnetic 
resonance imaging (MRI) service (72197) performed on June 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion (20930, 20939, 22612, 22614, 22843, 
22850, 27280, 61783). 
 
You asked the Plan to pre-approve spinal fusion. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 spinal fusion. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found no compelling rationale is presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested spinal fusion to treat scoliosis (T6-Pelvis fusion, open SI joint fusion, and hardware removal from T8-S1), in this case, 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 spinal fusion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal fusion (20930, 20939, 22612, 22614, 22843, 22850, 27280, 61783).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services that provided on August 23, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that the services were medically necessary and 
that you will accept the Medicare allowable rate.  The Plan denied your request. The Plan says there was no 
network deficiency, and the services could have been provided within the 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 laboratory services that provided on August 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 13, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that this should be processed as in-network. The Plan 
denied your request. The Plan says this was not authorized. 
 
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 an office visit provided on October 13, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that this is a Medicare-covered service. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. In addition, you 
did not bill with the required DEX Z-Code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a referral to a genetic counselor. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the Primary Care Physician (PCP) did not recommend this. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that genetic testing is recommended in the national guidelines for someone with a twin sister diagnosed 
with ovarian cancer, and a mother and a brother with unknown primary cancers. The enrollee would qualify for 
genetic counseling. 
 
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 referral have been met. Therefore, we decided that the Plan has to pre-
approve a referral to a genetic counselor.  
 
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 procedure code 84480-59 billed for date of service August 
25, 2022.  
 
You asked the Plan to pay for procedure code 84480-59. You say that you have submitted medical records to 
support payment. The Plan denied your request. The Plan says payment for code 84480-59 is bundled into 
payment for code 84481-59. 
 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 
84480-59 is a column II code to column I code 84481-59 with a modifier indicator of 0. The column II 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 84480-59 billed for date of service August 25, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed with diagnosis code A41.9 
rendered from July 15, 2021, to July 18, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the DRG was updated. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that while the enrollee was treated for a possible, ongoing urinary tract infection (UTI), his urine culture was 
reported as negative. As such, it is difficult to diagnosis either a UTI or sepsis due to a UTI. The enrollee had 
an episode of transient tachycardia, which was attributed to the UTI, but could just as well have been part of his 
chronic, intermittent chest pain and history of paroxysmal atrial fibrillation. There is no evidence that the 
enrollee had hypotension, hypoperfusion or organ failure, which can clearly be attributed to an infection.  As 
such, the billing of A41.9 is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services billed with diagnosis code A41.9 rendered from July 15, 2021, to July 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 12001 and 99285 rendered on November 4, 
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 the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 12001: 
 
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less 
 
CPT 99285: 
 
Emergency department visit for the evaluation and management of a patient, which requires these 3 key 
components within the constraints imposed by the urgency of the patient's clinical condition and/or mental 
status: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function 
 
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 emergency services provided 
do not support CPT 99285. The procedure report describes the history as comprehensive, the exam as 
comprehensive, but the medical decision making as moderately complex. There is a more appropriate code for 
these services. 
 
Additionally, an edit exists between CPT 12001 and 26770, with a modifier indicator of 1. A modifier was not 
billed to report these services as separate and distinct. 
 
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 procedure codes 12001 and 99285 rendered on November 4, 2022.