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

 
We decided that the Plan does not have to pay for procedure code 84480 billed for date of service March 1, 
2022.  
 
You asked the Plan to pay for procedure code 84480. The Plan denied your request. The Plan says payment for 
code 84480 is bundled into payment for code 84481. 
 
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 84480 is a column II code to column I code 84481 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 84480 billed for date of service March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 19, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on March 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair accessories (E0163, E0971, E0973, E2601, 
E2611, K0004, K0195) provided on February 10, 2022. 
 
You asked the Plan to pay for the wheelchair accessories. You say that these items were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. The records provided 
do not include a physician order for these items or features. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for wheelchair accessories (E0163, E0971, E0973, E2601, E2611, K0004, K0195) provided on 
February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code(s) 83735, 84443, 80164, & 80053  billed for 
date of service February 24, 2023. 
 
You asked the Plan to pay for procedure code(s) 83735, 84443, 80164, & 80053 . You say that these services 
were medically necessary. The Plan denied your request. The Plan says this code is included in the skilled 
nursing facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 83735, 84443, 80164, & 80053  has a Professional/Technical indicator of 1. This means 
that CPT code 83735, 84443, 80164, & 80053  has both a professional and technical component. In this case, 
CPT code 83735, 84443, 80164, & 80053  has not been billed with an appropriate modifier to indicate the 
professional component. Based on this information, we decided that Medicare rules for coverage of procedure 
code 83735, 84443, 80164, & 80053  have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 83735, 84443, 80164, & 80053  billed for date of service February 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 
87641 and 87500 billed for February 22, 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 procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500 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. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87491 is infectious agent 
detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 
code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique. The definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), not 
otherwise specified; amplified probe technique, each organism. The definition of code 87641 is infectious 
agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe 
technique. The definition of code 87500 is infectious agent detection by nucleic acid (DNA or RNA); 
vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500 are not supported in the 
medical record. Specifically, the file shows that a panel was performed and there is a more appropriate single 
code for these services. 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 procedure codes 
87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500 billed for February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 29, 2023, billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, 81294, 81432, and 81433. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 29, 2023, billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, 81294, 81432, and 
81433.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 3, 2023, to May 2, 
2023. 
 You asked the Plan to pay for the home health services. You say that the required NOA was submitted timely. 
The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied. The Plan says that although you claim that the NOA was submitted, none has been received. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from April 3, 2023, 
to May 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, electrical, non-invasive, 
other than spinal applications (E0747). 
 
You asked the Plan to pre-approve an electrical bone growth stimulator. You say that you are requesting 
reconsideration and have provided medical records for review. The Plan denied your request. The Plan says the 
request for a bone growth stimulator is not medically necessary because healing has not ceased for three or 
more months, and nine months have not elapsed since the open reduction and internal fixation (ORIF). 
 The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 electrical bone growth stimulator. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the diagnosis of 
nonunion has not been clearly established. Not enough time has passed since the surgery. The enrollee needs 
nine months total elapsed time since surgery. 
 
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 electrical bone growth stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an osteogenesis stimulator, electrical, non-invasive, other than spinal 
applications (E0747).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q9966 rendered on March 23, 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 Healthcare Common Procedure Coding System (HCPCS) code Q9966 (47) units remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code Q9966 is "Low osmolar contrast material, 200-299 
mg/ml iodine concentration, per ml." 
 
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 had epidural injections on 3/23/23 and a total of 3 ml of low osmolar contrast was utilized.  The op notes document that a 
50cc vial was used and the remaining 47 cc was discarded. The guidelines state that the smallest available vial 
of contrast be used for these procedures. While the discarded 47 cc was documented in the op report there are 
smaller vials commercially available including 10 cc vials. Thus, the discarding of the billed 47 cc was not 
necessary. 
 
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 procedure code Q9966 rendered on March 23, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services coded as 77080 performed on April 12, 
2023. 
 
You asked the Plan to pay for the imaging services. You say that the imaging services should be covered 
because they are supported in the documentation. The Plan denied your request. The Plan says 77080 is not 
covered because it was not billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that 77080 is only covered when billed with a valid 
diagnosis code that indicates the reason for the procedure is post-menopausal female, vertebral fracture, 
hyperparathyroidism, or steroid therapy. 
 
We looked at the file and Medicare rules. In this case, 77080 was billed with diagnosis code Z13.820, defined 
as encounter for screening of osteoporosis, and M85.80, defined as other specified disorders of bone density 
and structure, multiple sites. Neither of these diagnoses indicate the reason for the procedure is because the enrollee is a post-menopausal female, has a vertebral fracture, hyperparathyroidism, or has received steroid 
therapy. Based on this information, we decided that Medicare rules for coverage of the imaging services have 
not been met. Therefore, we decided that the Plan does not have to pay for the imaging services coded as 77080 
performed on April 12, 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 will be able to meet their activities of 
daily living, mobility goals and regain their independent life style after a short stay in an inpatient rehabilitation 
facility. The Plan denied your request. The Plan says an IRF admission 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: 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 inpatient rehabilitation is the only chance the 
enrollee may have at returning to prior level of activity and independence and regaining quality of life. The 
Plan denied your request. The Plan says criteria for admission to the acute IRF setting have not been met.  
 
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.
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 you are requesting an expedited appeal to allow the 
enrollee to go to the IRF as recommended by the physical therapist in the hospital. You say prior to their 
hospitalization, the enrollee was completely independent requiring no assistive devices and was driving. The 
Plan denied your request. The Plan says based on Medicare guidelines, 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.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient hospital stay to start a new medicine. 
 
You asked the Plan to pre-approve an inpatient hospital stay. You say that the patient is agreeable to Tikosyn 
(dofetilide) and is agreeable to being admitted for three days to initiate dofetilide. You also say that you would 
like this to be reconsidered for the safety of the patient. The Plan denied your request. The Plan says that the 
requested stay is not medically necessary. 
 
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 pre-approve an inpatient hospital stay. Our reviewer 
says that the documentation supports that the criteria for an inpatient stay are met in this case. Our physician 
reviewer found the record showed that the physician reasonably expects that the patient's necessary hospital 
care will span two 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 an inpatient hospital stay have been met. Therefore, we decided that the Plan 
has to pre-approve an inpatient hospital stay to start a new medicine.  
 
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 pre-approve sacroiliac joint injection. 
 
You asked the Plan to pre-approve the injection. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage 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 the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there are no sacroiliac joint injection diagnostic tests documented. The elements of the 
coverage criteria are not satisfied. The requested service cannot be covered 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint injection.