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

 
We decided that the Plan does not have to pay for the echocardiography (93306) provided May 14, 2023. 
 
You asked the Plan to pay for the echocardiography. You say that the claim should be paid. The Plan denied 
your request. The Plan says I51.7 and I08.3, should not be reported together. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the echocardiography have not been met. The diagnosis codes 
I51.7 (Cardiomegaly) and I08.3 (Combined rheumatic disorders of mitral, aortic and tricuspid valves), should 
not be reported together which is based on the Excludes1 Notes instructions in the ICD-10-CM Official 
Guidelines for Coding and Reporting. The billed service has been denied because it was reported with one or 
more diagnosis code pairs that are subject to an Excludes1 note.  Therefore, we decided that the Plan does not 
have to pay for the echocardiography (93306) provided May 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (G0483) provided June 13, 2023. 
 You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
Code G0483 remains not supported. The medical records submitted do not include an order that specifically list 
what test(s) are to be performed in the custom panel. Based on this information, we decided that Medicare rules 
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services (G0483) provided June 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64447-59-LT and 64445-59-LT provided on 
March 23, 2023. 
 You asked the Plan to pay for procedure codes 64447-59-LT and 64445-59-LT. You say that the medical 
records support the billing of codes 64447 and 64445 as distinct procedural services to code 01480. The Plan 
denied your request. The Plan says the medical records do not support the billing of codes 64447 and 64445 as 
distinct procedural services to code 01480. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that codes 64447 and 64445 are column II codes to column I code 01480; 
however, 64447 and 64445 were billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 64447-59-LT and 64445-59-LT. Our 
reviewer says that the medical records do not support the billing of codes 64447 and 64445 as distinct 
procedural services to code 01480. Our reviewer found for procedure codes 64447 and 64445, the medical 
records do not include sufficient documentation to confirm the injection was not integral to the anesthesia, to 
include surgeon request for injection for post operative pain, as well as the procedure report confirming 
separate procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 64447-59-LT and 64445-59-LT have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 64447-59-LT and 64445-59-LT provided on 
March 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for 
coverage of LTACH care. 
 
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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to currently not be stable and requires additional short-term 
acute care services that can safely be provided at the current facility until more stable and appropriate for 
transfer. The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to the LTACH is not medically necessary and would not be clinically advantageous. 
Completion of treatment at the current facility is recommended.  
 
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 long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says the requested neuropsychological testing 
does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is covered when the 
criteria listed in the Medicare rules section of this decision 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 neuropsychological testing. Our 
reviewer says that the requested neuropsychological testing is not considered reasonable and medically 
necessary in this case. Our physician reviewer found that based on review of the records provided, this enrollee 
has had difficulty with pain where the physician is requesting a cognitive assessment in order to prescribe 
opioid pain medication. The enrollees documentation shows the enrollee is taking aripiprazole and Klonopin. 
Utilizing the criteria from the Medicare LCD L34520 that this testing is intended to diagnose and characterize 
the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain including 
detection of neurologic disease based on quantitative assessment of neurocognitive abilities, differential 
diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of central 
nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous system 
disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or management 
strategies among individuals with neuropsychiatric disorders, this enrollee does not meet the criteria as the 
enrollee is not showing severity of symptoms that would warrant this type of diagnostic treatment and does 
therefore not appear medically necessary or reasonable. The neuropsychological testing as outlined 
documentation is unclear the reasoning for the testing to be obtained. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27702 billed for date of service March 13, 
2023.  
 
You asked the Plan to pay for procedure code 27702. You say that you disagree with the denial. 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 27702 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 27702 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 27702 billed for date of service March 13, 2023.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
requires full assist at baseline. Daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. The enrollees care needs are custodial and can, as a practical 
matter, be provided 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 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 the laboratory services (80307 and G0482) provided 
February 28, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 laboratory services have been met. 
Medical records were not provided to verify the services. Therefore, we decided that the Plan does not have to 
pay for the laboratory services (80307 and G0482) provided February 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72040 billed for date of service January 8, 
2023. 
 You asked the Plan to pay for procedure code 72040. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 72040 is bundled into payment for code 72052. 
 
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 72040 
is a column II code to column I code 72052. This claim 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 72040 billed for date of service January 8, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 25, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the information provided by the appellant does not include any 
documentation of this service was actually performed. 
 
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 physician's services have been met.  
Therefore, we decided that the Plan does not have to pay for physician's services provided on  
February 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  
 
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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
Health Plan. The documentation does not support that LTACH services are medically appropriate at this time. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease (DJD) or stenosis. The cause of the pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of the spinal cord stimulator (63685, 
63650). 
 
You asked the Plan to pre-approve replacement of the spinal cord stimulator. 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 all of the 
conditions have been 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 replacement of the spinal cord 
stimulator. Our reviewer says that the services are not medically necessary. Our physician reviewer found there 
is no damage to the device or lead fracture. There is no documentation of an underlying change in the spinal 
pathology. There is no documentation of the number of reprogramming attempts. The NCD limits the enrollee 
to one permanent spinal cord stimulator with provisions made for battery changes and changes of leads or the 
device with malfunction. There is no indication of any of these events. Therefore, the request is deemed 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 replacement of the spinal cord stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve replacement of the spinal cord stimulator (63685, 63650).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice or home health care provided in patient's home 
residence provided on February 11, 2021. 
 
You asked the Plan to pay for hospice or home health care provided in patient's home residence. You say that 
the claim was corrected several times and should not be denying for timely filing. The Plan denied your 
request. The Plan says time limits for filing a corrected claim must be submitted within 1 year from the date of 
the initial determination or redetermination for any reason. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for hospice or home health care provided in patient's home residence was not 
filed until April 6, 2023. This means that more than one calendar year from the date of service had passed 
before a claim was filed. Therefore, we decided that the Plan does not have to pay for hospice or home health 
care provided in patient's home residence provided on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test(s), 15-21 drug class(es), including metabolite(s) 
if performed (G0482) provided November 3, 2022. 
 
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the number of definitive urine drug classes requested are not 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 pay for the drug testing. Our physician reviewer 
found the review indicates that the medical record sent by the provider shows a direct to definitive UDT panel 
or multiple drug classes without first performing a presumptive screening UDT. The clinician has also not 
documented individualized patient concerns about risks in failing to identify non-prescribed medications or illicit substances, to be able to safely prescribe controlled substances. The review has determined that the 
number of definitive urine drug classes requested was not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug test(s), 15-21 drug class(es), including metabolite(s) if performed (G0482) provided 
November 3, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 2, 2022, to 
May 1, 2022. 
 
You asked the Plan to pay for the home health services. You say that the records support the code billed. The 
Plan denied your request. The Plan says the records do not support the billed health insurance prospective 
payment system (HIPPS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that a case-mix methodology adjusts the 30-day 
payment rate based on characteristics of the patient and his/her corresponding resource need. 
 We asked our physician 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 home health services. Our reviewer says that the 
documentation does not support the diagnosis code billed. Our reviewer found International Classification of 
Disease, 10th Edition, Clinical Modification (ICD-10-CM) code, Z48 (Encounter for attention to dressings, 
sutures, and drains) was utilized as the primary diagnosis code for this care with health insurance prospective 
payment system (HIPPS) code 1CC31 (4th position representing high comorbidity level). However, the 
provided documentation supports the pressure ulcer ICD code L89.522 would have been the most appropriate 
primary diagnosis, making the 1CC31 code unnecessary and inappropriate. Therefore, the medical records do 
not support the billed HIPPS code 1CC31 for these dates. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from April 2, 2022, to May 1, 2022.