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

 
We decided that the Plan does not have to pay for procedure codes 93010-59, 93010-76,59, 99291, 99292, and 
36556 billed for date of service February 8, 2023. 
 
You asked the Plan to pay for procedure codes 93010-59, 93010-76,59, 99291, 99292, and 36556. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says payment for codes 93010-59, 
93010-76,59, 99291, 99292, and 36556 are bundled into other codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also 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. The rules state that 
providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct 
procedural service. 
 
We looked at the file and Medicare rules. Codes 99291 and 99292 at issue were within the global surgery 
period of code 36556 provided on the same date of service. 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. 
 
In this case, we have confirmed that codes 93010 and 99292 are column II codes to column I code 36556. 
This claim has not been billed with an appropriate modifier to bypass the edit. While code 93010 was billed 
with modifier -59, the medical records provided do not show that the service billed with the -59 modifier is a 
distinct procedural service.  
 
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 codes 93010-59, 93010-76,59, 99291, 99292, and 36556 billed for date of 
service February 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic testing (81226) provided on March 
20, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the genetic testing. You say that you are requesting reconsideration of the denied 
services. The Plan denied your request. The Plan says the modifier billed shows the code as not covered by 
Medicare. Enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 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 GeneSight Psychotropic testing (81226) provided 
on March 20, 2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 36247, 36245, 99153, 75726, 99153, 47536, 75774, 
76937, and 99152 for date of service February 15, 2023. 
 
You asked the Plan to pay for codes 36247, 36245, 99153, 75726, 99153, 47536, 75774, 76937, and 99152. 
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 May 18, 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 codes 36247, 36245, 99153, 75726, 99153, 
47536, 75774, 76937, and 99152 have not been met. Therefore, we decided that the Plan does not have to pay 
for codes 36247, 36245, 99153, 75726, 99153, 47536, 75774, 76937, and 99152 for date of service February 
15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 27, 2022, billed 
with codes 87481, 87500, 87641, 87652, 87653, 87798, and 87900. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. 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 
September 27, 2022, billed with codes 87481, 87500, 87641, 87652, 87653, 87798, and 87900.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enhertu. 
 
You asked the Plan to pre-approve Enhertu. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Enhertu. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found The review has determined that the 
requested use of Enhertu is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of 
the major drug compendia or by clinical research that appears in a CMS-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Enhertu have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Enhertu.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 15, 2022, to 
December 14, 2022. 
 You asked the Plan to pay for the home health services. You say that your biller suddenly left, leaving you 
unable to submit your NOA timely. The Plan denied your request. The Plan says the NOA was not received 
timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 15, 2022. The NOA was not received by the Plan until March 3, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from November 15, 2022, to December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx panel provided on April 6, 
2022. 
 
You asked the Plan to pay for the FoundationOne Liquid CDx panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this 
testing. 
 
The Plan must follow Medicare rules. Medicare rules say that this testing is covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. In this case the record does not show that the enrollee has either 
recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Based on this information, we 
decided that Medicare rules for coverage of the FoundationOne Liquid CDx panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the FoundationOne Liquid CDx panel provided on 
April 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77067 and 77063 for date of service 
February 22, 2023. 
 
You asked the Plan to pay for procedure codes 77067 and 77063. 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 28, 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 codes 77067 and 77063 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 77067 and 77063 for 
date of service February 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99397 billed for date of service February 13, 
2023. 
 
You asked the Plan to pay for procedure code 99397. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99397 is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code 99397 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code 99397 is not covered. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99397 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99397 billed for date of service February 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
November 15, 2022, to December 1, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee was treated for post-
surgical edema and inflammation and post-surgical lymphedema. The Plan denied your request. The Plan says 
pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided November 15, 2022, to December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service March 26, 
2023. 
 
You asked the Plan to pay for procedure code 99140. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99140 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service March 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kate Farms Standard 1.0. 
 
You asked the Plan to pre-approve Kate Farms Standard 1.0. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that enteral nutrition is covered when specific criteria are 
met. 
 
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 Kate Farms Standard 1.0. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found this enrollee is on Kate Farms 
supplements. Although she has a diagnosis of underweight there is no documentation of why this is occurring 
and therefore unclear if it is warranted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Kate Farms Standard 1.0 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Kate Farms Standard 1.0.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency-department visit (99285) billed for date of 
service March 4, 2023. 
 
You asked the Plan to pay for emergency-department visit. You say that you have billed the services at issue 
correctly. 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 43762 
provided on March 4, 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 emergency-department visit (99285) 
billed for date of service March 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (procedure code 99305) rendered 
on April 19, 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 99305 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 99305 is "Initial nursing facility care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using total time on the date of the encounter for code 
selection, 35 minutes must be met or exceeded." 
 
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 documentation does not 
support an appropriate exam, an appropriate history or medical decision making of moderate level, or that 35 
minutes or more were spent on this 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 initial nursing facility care (procedure code 99305) rendered on April 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy system (E0697). 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that the item is medically necessary. 
The Plan denied your request. The Plan says there is no indication that the enrollee is homebound, nor any 
other reason that he would be unable to received UV light treatment in a clinic, office, or outpatient hospital 
facility. 
 
The Plan follows Medicare rules. Medicare rules say that ultraviolet light therapy systems are covered for 
selected patients with generalized intractable psoriasis when medical and other factors justify treatment at 
home rather than at alternative sites, e.g., outpatient department of a hospital. 
 
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 ultraviolet light therapy system. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found there is no indication that 
the enrollee is homebound, nor any other reason that he would be unable to received UV light treatment in a clinic, office, or outpatient hospital facility. 
 
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 ultraviolet light therapy system have not been met. Therefore, we decided 
that the Plan does not have to pay for the ultraviolet (UV) light therapy system (E0697).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crutches (E0114) and knee brace (L1830) provided on 
May 11, 2023. 
 
You asked the Plan to pay for the crutches (E0114) and knee brace (L1830). You say that the items should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the crutches (E0114) 
and knee brace (L1830) provided on May 11, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a spinal cord stimulator (SCS) implant 
(63650). 
 
You asked the Plan to pre-approve insertion of an SCS implant. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 
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 insertion of an SCS implant. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found records show that the 
enrollee already has a stimulator with 2 leads for back pain. SCS is experimental for abdominal pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an SCS implant have not been met. Therefore, we decided that the 
Plan does not have to pre-approve insertion of a spinal cord stimulator (SCS) implant (63650).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and is a 
covered benefit. 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 September 25, 2022.