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

 
We decided that the Plan has to pay for procedure codes 81225, 81226, 81240, 81241, and 81328 for date of 
service March 13, 2023. 
 
You asked the Plan to pay for procedure codes 81225, 81226, 81240, 81241, and 81328. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says that the submitted molecular 
pathology codes were not submitted with the required DEX Z-code. 
 
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 the submitted molecular pathology codes were not submitted 
with the required DEX Z-code. The documentation did not include Medicare rules so support that a DEX-Z 
code is required for these services rendered. No other denial rationale was provided. The Plan did not 
substantiate their denial. Therefore, we decided that the Plan has to pay for procedure codes 81225, 81226, 
81240, 81241, and 81328 for date of service March 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 46999 rendered on June 7, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is a more specific code for the services 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 46999 is "Unlisted procedure, anus." 
 
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 in this case, the procedure report 
describes excision of a single external tag, anus, was performed. There is a more specific code to report for this. 
CPT 46999 is reported for procedures of the anus that do not have a specific code.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 46999 rendered on June 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx (0239U) provided June 26, 
2022. 
 
You asked the Plan to pay for the genetic testing. You say that FoundationOne Liquid CDx is a medically 
necessary laboratory test or patients with advanced stage, solid tumor cancers who have decided to seek further 
treatment. The Plan denied your request. The Plan says this service does not meet the Medicare criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records do not show that the enrollee's cancer is either recurrent, 
relapsed, refractory, metastatic, or advanced stage III or IV cancer. Per the test requisition form in the provided 
records, the disease status at the time of testing indicates none. 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 FoundationOne Liquid CDx (0239U) provided June 26, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 18, 2023, to May 
23, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be reprocessed and paid. 
The Plan denied your request. The Plan says that the services in this case were not urgent or emergent. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the provided documentation indicates the enrollee presented to the emergency department (ED) 
on May 18, 2023, with an exacerbation of chronic obstructive pulmonary disease (COPD) and congestive heart 
failure (CHF). The documentation supports that the enrollee was treated with intravenous (IV) steroids and IV 
Lasix. The documentation supports the enrollee had stabilized by May 23, 2023, when they were discharged. 
Therefore, the reviewer found that the record supports that at the time of inpatient admission it was reasonable 
for the admitting physician to expect that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights with supporting documentation of the enrollees history and 
comorbidities, signs and symptoms, current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from May 18, 2023, to May 23, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing (81479) provided on 
April 3, 2023. 
 
You asked the Plan to pay for the Guardant Reveal diagnostic testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests such as the 
Guardant Reveal are subject to the MolDX application, assessment, and approval process. 
 We looked at the file and Medicare rules. We find that the Guardant Reveal test has not been approved for 
coverage based on information in the DEX Diagnostic Exchange. Based on this information, we decided that 
Medicare rules for coverage of the Guardant Reveal diagnostic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant Reveal diagnostic testing (81479) provided on 
April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96413 billed for date of service May 9, 2023. 
 
You asked the Plan to pay for the billed services. You say that this is a payable service. The Plan denied your 
request. The Plan says the service does not meet coding standards. 
 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 96413 is chemotherapy administration, intravenous 
infusion technique; up to 1 hour, single or initial substance/drug. We find that CPT code 96413 is not supported 
in the medical record. CPT code 96413 was billed with drug code J1602, golimumab (Simponi Aria). This drug 
code should not be billed using a chemotherapy administration code. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 96413 billed for date of service May 9, 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 LTACH services are medically 
necessary. The Plan denied your request. The Plan says LTACH 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 services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting as provided 
by the health Plan. The documentation does not support that LTACH services are medically appropriate. 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core build-up (D2950) for teeth #22 and #27. 
 
You asked the Plan to pre-approve D2950. You say that a core build-up is medically necessary. The Plan 
denied your request. The Plan says there is enough tooth remaining that a core build-up is not necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers D2950 when 
the services are medically necessary and reasonable.  
 
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 D2950. Our reviewer says that D2950 
is not medically necessary. Our physician reviewer found documentation indicates that teeth #22 and #27 have been approved for retainer crowns for a fixed bridge replacing missing teeth #'s 23, 24, 25 and 26. A core build 
up is required when there is significant coronal breakdown which would reduce the retention and support of a 
crown restoration. Teeth #'s 22 and 27 do not appear to have significant coronal breakdown which would affect 
the retention of the proposed retainer crowns. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D2950 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a core build-up (D2950) for teeth #22 and #27.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 31622, 31624, and 31625 billed for date of 
service May 12, 2023.  
 
You asked the Plan to pay for procedure code 31622. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 31622 is bundled into payment for code 31625. 
 
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 31622 is a column II code to column I code 31625 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.  
 
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 31624 is Bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with bronchial alveolar lavage. The definition of code 31625 is 
bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or 
endobronchial biopsy(s), single or multiple sites. 
 
We find that CPT codes 31624 and 31625 are not supported in the medical record. Specifically, the records do 
not include the enrollees name to support the services were performed. 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 31622, 31624, and 31625 billed 
for date of service May 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99239) provided on March 3, 2023. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 find that CPT code 99239 is not supported in the medical record. Specifically, the code billed is for 
inpatient or observation care, however the claim was billed with place of service 23 (emergency room). An 
emergency room code was not billed. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services (99239) provided on March 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate. 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that this is medically necessary. The 
Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested bone marrow aspirate is not considered medically reasonable and necessary in this case. 
Our physician reviewer found bone marrow aspirate is experimental for use as bone graft material in spine surgery. Therefore, the reviewer found that the requested bone marrow aspirate 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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs this level of care. The Plan 
denied your request. The Plan says the records do not show a need for SNF services, and needs can be met at 
another level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345-GZ billed for date of service March 
21, 2023. 
 
You asked the Plan to pay for procedure code 81345-GZ. You say that the documentation shows medical 
necessity. The Plan denied your request. The Plan says payment for code 81345-GZ is bundled into payment 
for code 0089U. 
 
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 81345-GZ is a column II code to column I code 0089U. Code 81345 
has not been billed with an appropriate modifier to bypass the edit. 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 
81345-GZ billed for date of service March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency-department visit (99284) on April 22, 2023. 
 
You asked the Plan to pay for an emergency-department visit. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the service at issue was not billed with 
the required modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 64400 
provided on April 22, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for an emergency-department visit 
(99284) on April 22, 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 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you believe the treatment sought is 
medically necessary to to treat the enrollee based on their medical condition. 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 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335 and 81238.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88312, 88313, and 88342 billed for date of 
service June 15, 2023.  
 
You asked the Plan to pay for procedure code 88312, 88313, and 88342. You say that the additional units were 
medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88312 is 9. The MAI value for this code is 3. You billed 12 units of this 
code, exceeding the MUE. The MUE for CPT code 88313 is 8. The MAI value for this code is 3. You billed 12 
units of this code, exceeding the MUE. The MUE for CPT code 88342 is 4. The MAI value for this code is 3. 
You billed 10 units of this code, exceeding the MUE. 
 
For each of these codes, the documentation does not show that the excess units were correctly coded and 
medically necessary. The records do not clearly show why the medically accepted number of units were not 
adequate enough for testing in this case. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
88312, 88313, and 88342 billed for date of service June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service 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 February 21, 2022.