Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home delivered prepared meals. 
 
You asked the Plan to pre-approve additional home delivered prepared meals. You say that after post-surgery, 
you are still in a lot of pain. You also say that being that you will be 80 years old in two months doesn't help. 
You also say that home delivered meals are needed.  The Plan denied your request. The Plan says you do not 
meet the coverage criteria established. 
 The Plan must follow Medicare rules. Medicare rules say that meals may be offered as a supplemental benefit 
immediately following surgery or an inpatient hospital stay, for a temporary duration, typically a four-week 
period, per enrollee per year, provided they are ordered by a physician or non-physician practitioner.  
 
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 additional home delivered prepared 
meals (S5170). Our reviewer says that this request for home delivered meals is not medically necessary based 
on the provided documentation. Our physician reviewer found there is insufficient recent documentation of 
your nephrologist or other physicians discussing your prolonged pain or your needs including treatment 
changes or home delivered meals to help justify this request for an extension beyond the expected need. 
 
We looked at this physician's review, the file, and Medicare rules. The Plan rules say that they cover up to two 
meals per day in a consecutive four-week period, once per calendar year. The record shows this benefit has 
been exhausted and is not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of additional home delivered prepared meals have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home delivered prepared meals.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 64415-59 billed for date of service March 1, 2023. 
 
You asked the Plan to pay for code 64415-59. You say that this code is not bundled into 01744 because it was 
ordered and provided for post-operative pain management. The Plan denied your request. The Plan says code 
64415-59 is not supported by the medical record. This code is included in code 01744 and cannot be separately 
reimbursed. The records don't support that the procedure was distinct or independent from other services 
performed. 
 The Plan must follow Medicare rules. 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 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 code 64415-59. Our reviewer says that the 
use of the 59 modifier with code 64415 is not supported by the medical record.  Our physician reviewer found 
According to CPT and NCCI rules, a nerve block can be reported separately only when the surgeon requests it 
for postoperative pain management. The record does not state that the nerve block was requested by the 
surgeon for postoperative pain management. Therefore, it is included in the anesthesia for the procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 64415-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 64415-59 billed for date of service March 1, 2023.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a leadless pacemaker. 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that a leadless pacemaker is medically 
necessary. The Plan denied your request. The Plan says that the requested leadless pacemaker does not meet the 
Medicare NCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that a leadless pacemaker 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 a leadless pacemaker. Our reviewer 
says that the requested leadless pacemaker is considered medically reasonable and necessary in this case. Our 
physician reviewer found recent guidelines are consistent with the appropriateness of selecting a leadless, as 
opposed to a traditional, pacemaker, as the leadless system has certain advantages in this setting, particularly 
with chronic atrial fibrillation, where an atrial lead is unnecessary. This selection should be looked upon as 
being at the discretion of the treating physician. Therefore, use of a leadless pacemaker would be considered 
medically appropriate and reasonable in this patients clinical management. 
 
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 leadless pacemaker have been met. Therefore, we decided that the Plan has to 
pre-approve a leadless pacemaker.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 19, 2023. 
 
You asked the Plan to pay for lab tests. You say that this testing should be paid in full due to its clinical value. 
The Plan denied your request. The Plan says there is a more appropriate panel code which should be billed, 
87633. 
 
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 87486 is chlamydia pneumoniae, amplified probe 
technique. The CPT Code Manual definition of code 87496 is cytomegalovirus, amplified probe technique. The 
CPT Code Manual definition of code 87498 enterovirus, amplified probe technique, includes reverse 
transcription when performed. The CPT Code Manual definition of code 87502 is influenza virus, for multiple 
types or sub-types includes multiplex reverse transcription, when performed, and multiplex amplified probe 
technique, first 2 types of sub-types. The CPT Code Manual definition of code 87532 is herpes virus 6, amplified probe technique. The CPT Code Manual definition of code 87541 is legionella, pneumophila, 
amplified probe technique. The CPT Code Manual definition of code 87581 is mycoplasma pneumoniae, 
amplified probe technique. The CPT Code Manual definition of code 87640 staphylococcus aureus, amplified 
technique. The CPT Code Manual definition of code 87651 streptococcus, group A amplified probe technique. 
The CPT Code Manual definition of code 87798 is infectious agent detection by nucleic acid, not otherwise 
specified, amplified probe technique. The CPT Code Manual definition of code U0004 is COVID-19, any 
technique, multiple types or subtypes, making use of high throughput technologies as described by Medicare. 
The CPT Code Manual definition of code U0005 is infectious agent detection by nucleic acid; severe acute 
respiratory syndrome coronavirus 2, amplified probe technique, making use of high throughput technologies 
completed within 2 calendar days from date of specimen collection as described by Medicare. 
 
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 lab tests. Our reviewer says that these codes do not meet 
criteria for payment. Our reviewer found that the records include an order for a respiratory panel. In this case, 
there is a multiple types or subtypes panel code which would include this procedure. Billing multiple procedure 
codes when a panel code exists resulted in unbundling. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on January 19, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 83520 and 87798 billed for date of service December 
20, 2022. 
 
You asked the Plan to pay for procedure codes 83520 and 87798. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says that these codes are not 
supported 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 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 83520 and 87798. Our reviewer says that 
these codes are supported in the records provided. Our reviewer found stool testing documents infectious agent 
antigen and immunoassay analytes so codes 87798 and 83520 are justified. 
 
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 83520 and 87798 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 83520 and 87798 billed for date of service December 20, 2022.  
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 37253 and 75625 billed for date of service March 9, 
2023. 
 
You asked the Plan to pay for procedure codes 37253 and 75625. You say that these services are supported as 
billed. The Plan denied your request. The Plan says that these codes are not supported in the records provided. 
 
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 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 37253 and 75625. Our reviewer says that 
these codes are supported. Our reviewer found the documentation specifically describes ultrasound-guided 
access of left common femoral artery and intravascular ultrasound of several arteries, so CPT codes 37253 and 
75625 are justified. 
 
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 37253 and 75625 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 37253 and 75625 billed for date of service March 9, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on May 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 the presentation was not one of high severity requiring urgent evaluation and no acute situation 
of a complex nature to support the level of care 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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making." 
 
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 supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level. 
 
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 99284) rendered on May 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospitalization provided from December 3, 
2022, to December 5, 2022. 
 You asked the Plan to pay for the inpatient hospitalization. You say that you would like the determination of 
the services provided to be based on the initial perceived risk for adverse events, complexity of this specific 
patient's case, and medical necessity for inpatient care. The Plan denied your request. The Plan says the clinical 
does not support a reasonable expectation that the enrollee would require hospital services extending beyond 2 
midnights. The Plan also says that transfusion and hematology consultation, if necessary, could be reasonably 
expected to be performed in an observation status. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospitalization. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented with dizziness in the setting of chronic anemia, having stopped 
iron supplementation. Workup revealed Hemoglobin (Hgb) 3. Our reviewer also found that the enrollee was 
treated with blood transfusion and intravenous iron. Repeat Hgb was 8. Vitals remained stable during 
treatment, there was no evidence of an active bleed, and the enrollee could tolerate oral iron. Our physician 
reviewer found that therefore, it was not expected that the enrollee would have required hospital services that 
would have likely crossed 2 midnights.  
 
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 inpatient hospitalization have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospitalization provided from December 3, 2022, to December 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory panel testing provided on May 4, 2023. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this panel testing is characterized as a single unit of service and cannot be 
unbundled. 
 
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 pay for lab tests. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found no clinical records have been provided showing medical necessity of the testing and why more 
standard testing such as a wound culture and sensitivity was inadequate for evaluation of the condition. 
Records also fail to include a diagnosis or records of infection; records only report an open wound with no 
reported complications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory panel testing provided on May 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OnkoSight Advanced NGS Myeloid Panel (81450) 
provided May 3, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the medical records provided will show 
proof of medical necessity.  The Plan denied your request. The Plan says under Medicare, the genetic testing, 
OnkoSight Advanced NGS Myeloid panel requested 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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found OnkoSight is a line of Next-Generation Sequencing (NGS) assays for hematologic 
malignancies and solid tumors that focuses on only actionable mutations in common cancers. This targeted approach helps personalize patient treatment and management. The NGS assay is not used to rule out cancer as 
part of diagnosis but to help find targeted treatments of the cancer. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the OnkoSight Advanced NGS Myeloid Panel (81450) provided May 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93571-26) provided on April 21, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code and 
modifier are 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. 
 
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 use of code 93571 
and modifier 26 is not supported by the records provided. Our reviewer found that the record states that an 
instantaneous wave-free ratio (IFR) was performed. According to CPT Assistant, this procedure should be 
reported with CPT code 93571 and modifier 52 to indicate reduced services. 
 
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 the services (93571-26) provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 7, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 25, 2023, to 
April 23, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the claim was billed correctly. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. 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 March 25, 2023, to April 
23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 0326U for date of service September 30, 2022. 
 
You asked the Plan to pay for code 0326U. 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 11, 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 code 0326U have not been met. Therefore, 
we decided that the Plan does not have to pay for code 0326U for date of service September 30, 2022.