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

 
We decided that the Plan does not have to pay for the hereditary CGx comprehensive complete cancer panel 
provided on November 28, 2022, and billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 
81317, 81321, 81351, 81209, 81314, 81334, 81345, 81272, and 81479. 
 
You asked the Plan to pay for the hereditary CGx comprehensive complete cancer panel. You say that this 
testing was medically necessary. The Plan denied your request. The Plan says this testing should be billed with 
a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the hereditary CGx comprehensive 
complete cancer panel  have not been met. Therefore, we decided that the Plan does not have to pay for the 
hereditary CGx comprehensive complete cancer panel provided on November 28, 2022, and billed with codes 
81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 81314, 81334, 81345, 81272, 
and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 28, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services are not covered when 
provided OON. 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 laboratory services 
provided on March 28, 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee is receiving services needed at the current hospital no 
reason for transfer at this time.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 21, 2023, to April 26, 
2023, billed with procedure code G0378. 
 
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 billed code has a status indicator N and is not 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code G0378 is not supported in the medical record. Specifically, we have confirmed that 
code G0378 has a status indicator N and is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 21, 2023, to April 26, 2023, billed 
with procedure code G0378.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73560-26 XU RT and 73560-26 XU LT 
billed for date of service July 21, 2023. 
 You asked the Plan to pay for procedure code 73560-26 XU RT and 73560 26 XU LT. You say that CPT codes 
73560-26 XU RT And 73560 26 XU LT were billed correctly, and the claim should be paid. The Plan denied 
your request. The Plan says payment for code 73560-26 XU RT and 73560 26 XU LT is bundled into payment 
for code 73562-26 RT And 73562-26 LT. 
 
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 73560 
is a column II code to column I code 73562. Though the column II code was reported with a modifier, there is 
no evidence that these two x-ray procedures were distinct. The three-view x-ray and the two-view x-ray were 
performed in the same session for the same indication. As such, separately reporting them is not supported.  
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 73560-26 XU RT and 73560-26 XU LT billed for date of service July 
21, 2023.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 88350 billed for date of service May 31, 
2023.  
 
You asked the Plan to pay for procedure code 88350. 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 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 88350 is 9. The MAI value for this code is 3. You billed 10 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88350 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88350 billed for date of service May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 14, 2022, billed with 
codes 81216, 81238, 81241, 81242, 81249, 81279, 81298, 81307, 81311, 81317, 81321, 81334 and 81339. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. 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 
October 14, 2022, billed with codes 81216, 81238, 81241, 81242, 81249, 81279, 81298, 81307, 81311, 81317, 
81321, 81334 and 81339.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services (71045, R0070, Q0092) provided on 
June 19, 2023. 
 
You asked the Plan to pay for the portable x-ray 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. 
 
We find that CPT codes 71045, R0070, & Q0092 are not supported in the medical record. Specifically, the 
records show the enrollee was covered under a Part A Skilled Nursing Facility (SNF) stay, however the claim 
was not billed with the required Place of Service 31. Technical services are subject to SNF consolidated billing. 
Based on this information, we decided that Medicare rules for coverage of the portable x-ray services have not 
been met. Therefore, we decided that the Plan does not have to pay for portable x-ray services (71045, R0070, 
Q0092) provided on June 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel provided May 2, 2023, billed with 
codes 87150, 87481, 87641, 87653, 87798, 87801. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a 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 laboratory testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel provided May 
2, 2023, billed with codes 87150, 87481, 87641, 87653, 87798, 87801.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (87486, 87541, 87581, 87640, 87637, U0003, 
U0005, 87631) provided on August 22, 2022. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 lab testing have been met. No 
clinical records were provided to show that coverage criteria was met for this testing. Records were limited to 
lab orders and results. The plan requested additional records and none were provided. Therefore, we decided 
that the Plan does not have to pay for lab testing (87486, 87541, 87581, 87640, 87637, U0003, U0005, 87631) 
provided on August 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for July 31, 2023. 
 
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 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 62321 
provided on July 31, 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 procedure code J3490 billed for July 
31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 11, 2023, billed with 
procedure code 99291. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the claim was billed with an inappropriate 
diagnosis code. 
 
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. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. This claim was billed with diagnosis codes 
S22.41XA and S22.42XA which is inappropriate since there is a bilateral diagnosis code available. Therefore, 
we decided that the Plan does not have to pay for practitioner services provided on May 11, 2023, billed with 
procedure code 99291.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service July 2, 2023. 
 
You asked the Plan to pay for code 99285. You say that this claim was underpaid. The Plan denied your 
request. The Plan says code 99285 is not supported by the medical record. The enrollee was hemodynamically 
stable, with normal vital signs and unremarkable lab work. There was no sign of multisystem dysfunction, a 
condition that posed an immediate life threat, nor no acute situation of a complex nature to support the level of 
care billed. No specialty consults or extensive decision making was required. No critical or extensive care was 
involved. As a result, this service was down-coded to 99284. 
 
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.  
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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical records. Our reviewer found the documentation does not support this level of medical 
decision-making complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service July 2, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the hospital evaluation and management (EM) services provided on 
April 11, 2023.  
 
You asked the Plan to pay for the EM services. You say that the records support the services billed.  The Plan 
denied your request. The Plan says that this was denied for lack of authorization.  
 
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 denied this claim for lack of authorization for out-of-network care. 
However, this service was related to a hospital admission from the emergency department. It is not appropriate 
to require authorization from non-network doctors seeing the enrollee is a hospital setting. As no alternate 
rationale was given, we find this denial is not supported.  Therefore, we decided that the Plan has to pay for the 
hospital evaluation and management (EM) services provided on April 11, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on July 18, 2023, billed with 
procedure code 99202. 
 
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 claim was billed with an inappropriate 
procedure code.  
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 99202 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99202 is not supported in the medical record. Specifically, documentation shows that 
services described by code 99213 were previously provided on June 13, 2022, and paid on July 7, 2022. As 
such, code 99202 is not supported. Based on this information, we decided that Medicare rules for coverage of 
the practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for practitioner services provided on July 18, 2023, billed with procedure code 99202.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 15, 2023, billed with 
codes 81162, 81218, and 81209. 
 
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 
March 15, 2023, billed with codes 81162, 81218, and 81209.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95939, 95938, 95861, 95865, 95868, 95937, 
and G0453 billed with diagnosis codes M50.90 and M54.2 provided on May 15, 2023. 
 
You asked the Plan to pay for procedure codes 95939, 95938, 95861, 95865, 95868, 95937, and G0453. You 
say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan 
says two of the billed diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that M54.2 has an Excludes1 note in relation to M50.90. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for procedure codes 95939, 95938, 95861, 95865, 95868, 95937, and G0453 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 95939, 95938, 95861, 95865, 
95868, 95937, and G0453 billed with diagnosis codes M50.90 and M54.2 provided on May 15, 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 meets the criteria and is at equilibrium 
regarding stability/acute need. You also say the enrollee will benefit from these services that cannot be 
accomplished at a lower level of care. The Plan denied your request. The Plan says admission to an IRF is not 
medically necessary.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 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.