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

 
We decided that the Plan does not have to pay for practitioner services provided on September 1, 2022, to 
September 17, 2022. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the additional documentation requested has not 
been received. 
 
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 practitioner services provided have 
been met. Specifically, an itemized bill summary has not been provided for review. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on September 1, 2022, to September 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on November 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims are billed based on the billed 
HIPPS code. 
 
We looked at the file and Medicare rules. The file shows that the records do not support the billed HIPPS code. 
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 the home health services rendered on November 
11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 19120 and 19350 billed for date of service 
November 14, 2022.  
 
You asked the Plan to pay for procedure codes 19120 and 19350. 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 codes 19120 and 19350 is 1. The MAI value for these codes is 2. You billed 2 
units of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 19120 and 19350 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 19120 and 19350 billed for date of service November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27394 billed for date of service March 16, 
2023. 
 You asked the Plan to pay for procedure code 27394. The Plan denied your request. The Plan says payment for 
code 27394 is bundled into payment for code 27435. 
 
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 27394 
is a column II code to column I code 27435. 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 27394 billed for date of service March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 22, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
payable for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital.   
 
We looked at the file and Medicare rules. The services were provided by a freestanding emergency facility that 
is not affiliated with a hospital. 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 the services provided 
on March 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 23, 
2023. 
 You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for 
code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service April 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 6, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the OON laboratory services. You say that the enrollee was receiving treatment 
at a dialysis facility and the services were medically necessary.  The Plan denied your request. The Plan says 
the OON services were not authorized or referred by a participating provider.  
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided on March 6, 2023, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) testing rendered 
on December 7, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. 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 the urine polymerase chain reaction 
(PCR) testing rendered on December 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from May 8, 2021, to June 
2, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed with a valid HIPPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims are paid based on the billed 
HIPPS code. 
 
We looked at the file and Medicare rules. The file shows that the billed HIPPS code is not valid and does not 
match the submitted documentation. 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 the home health 
services rendered from May 8, 2021, to June 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed. 
 The Plan follows Medicare rules. The rules say that home health services must include documentation showing 
the OASIS, plan of care, valid orders, visit note documentation, and physical therapy evaluation. 
 
We reviewed the file and the Medicare rules. We find that the medical records did not contain the OASIS, plan 
of care, valid orders, visit note documentation, and physical therapy evaluation. Without this documentation, 
the claim cannot be processed as submitted. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from July 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve 
(Intracept) procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says vertebrogenic pain is not a 
qualifying diagnosis. The Plan also says that the Intracept procedure 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 Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found additional study is needed to validate any benefit of the procedure, and to 
compare it to other interventions. Current medical literature indicates that the Intracept procedure is investigational at this time. Therefore, the reviewer found that the requested Intracept procedure is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve (Intracept) procedure 
(64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Liquid Biopsy CGP Panel (81455) provided 
January 31, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that this letter and the attached documents support 
the medical necessity of the test requested, to assist in the treatment, prognosis, and diagnosis for this type of 
cancer. The Plan denied your request. The Plan says the request does not meet Medicare rules as the testing 
performed was not FDA approved.  
 
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 testing performed was not FDA approved. 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 Tempus Liquid Biopsy CGP Panel (81455) provided 
January 31, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on November 26, 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 code 99285 is "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 enrollee was treated in the 
emergency room on November 26, 2022. The documentation from that date describes the enrollee as presenting 
with flu symptoms. The history was brief and described the enrollee with sinus congestion, sore throat, body 
aches, and headache with contact with daughter who had similar symptoms. The physical examination was 
comprehensive but revealed clear lungs, normal mouth and ear exam but with sinus tenderness in the maxillary 
sinuses. The enrollee's vitals were stable. The plan was for no further intervention. Based on the 
documentation, there was no support for medical decision-making of high complexity or of significant threat to 
life or function. 
 
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 emergency room services (procedure code 99285) rendered on November 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 27, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates that these tests should be included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 
20, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 20, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready to go the next level of care and 
it needs to be inpatient rehabilitation. You say the healthcare providers believe the enrollee should go to 
inpatient rehabilitation. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter embolization (61624). 
 
You asked the Plan to pre-approve a transcatheter embolization. You say that a transcatheter embolization is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says a transcatheter embolization is 
experimental/investigational for the enrollee's condition. 
 
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 a transcatheter embolization. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is support in the medical literature for middle meningeal artery 
transcatheter embolization for chronic subdural hematoma; however, provided records in this case do not 
support a diagnosis of chronic subdural hematoma. The records document an acute to subacute subdural hematoma. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a transcatheter embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a transcatheter embolization (61624).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 30, 2023, billed with 
procedure code 93971. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. This claim was billed with diagnosis codes 
R22.42 and R22.41 which is inappropriate when a bilateral diagnosis is provided. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on January 30, 2023, billed with procedure code 
93971.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from October 22, 2021, 
to January 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 a corrected claim has not been submitted. 
 
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 services have been met. Despite 
multiple attempts from the plan, a corrected claim to fix any discrepancies between the UB-04 and itemized bill 
has not been submitted. At this time, the services cannot be fully verified. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital services rendered from October 22, 2021, to January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will require continued medical 
management of comorbidities and polypharmacy needs, as well as daily physical and occupational therapies to 
address current deficits. The Plan denied your request. The Plan says the IRF services requested do not meet 
the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.