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

 
We decided that the Plan does not have to pay for lab services provided on June 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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 lab services provided on June 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve selective catheter placement, arterial system (prostate 
artery embolization - PAE) (36247). 
 
You asked the Plan to pre-approve the PAE. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this is considered experimental and therefore is not covered. 
 
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 PAE. Our reviewer says that the 
requested prostate artery embolization (PAE) is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this is considered an experimental technique to treat symptomatic benign 
prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. 
Therefore, the reviewer found that the requested PAE is not medically reasonable and 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 PAE have not been met. Therefore, we decided that the Plan does not have 
to pre-approve selective catheter placement, arterial system (prostate artery embolization - PAE) (36247).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided May 8, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that you are requesting reconsideration for 
services advising the coding department has reviewed the services and determined that the claim is coded 
correctly. The Plan denied your request. The Plan says the diagnosis codes should not be reported together 
which is based on the Excludes1 Notes instructions in the ICD-10-CM Official Guidelines for Coding and 
Reporting. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The diagnosis codes associated 
to C95.01 (Acute leukemia of unspecified cell type, in remission) and Z85.6 (Personal history of leukemia), 
should not be reported together per the 2023 ICD-10-CM Tabular. The billed service has been denied because 
it was reported with one or more diagnosis code pairs that are subject to an Excludes1 note. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided May 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on August 3, 2023, and billed with codes 87798 and 87481. 
 
You asked the Plan to pay for the urine PCR 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 urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
testing provided on August 3, 2023, and billed with codes 87798 and 87481.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 00560 and 36620. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 99100. 
 
You asked the Plan to pay for codes 00560, 36620, and 99100 billed on date of service May 17, 2023. You say 
that 00560, 36620, and 99100 should be paid as billed because they are supported in the medical record. The 
Plan says that 00560 and 36620 are being handled as an original decision reopen for New and Material 
Evidence, therefore no coverage decision was made. 99100 is considered bundled and not separately payable. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 00560 and 36620.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 00560 and 36620.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99100. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. 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 the services described by procedure code(s) 99100 
have not been met. Therefore, we decided that the Plan does not have to pay for the services described by 
procedure code(s) 99100. 
 
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: Favorable

 
We decided that the Plan has to pre-approve 12 fractions of intensity-modulated/image-guided radiation 
therapy (IMRT/IGRT). 
 
You asked the Plan to pre-approve IMRT/IGRT. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IMRT/IGRT. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found IMRT is a treatment planning tool, and its use may be appropriate for select patients in which 
the clinician wants to minimize dose to the surrounding tissues.  Reduction in kidney dose and/or heart doses is 
a valid argument to use IMRT for gastric mucosa-assisted lymphoid tissue (MALT) lymphomas, and the case 
records did adequately show this to be the case. IMRT would be within accepted standards 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 IMRT/IGRT have been met. Therefore, we decided that the Plan has to pre-
approve 12 fractions of intensity-modulated/image-guided radiation therapy (IMRT/IGRT).  
 
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: 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 IRF care is necessary. The Plan denied your request. 
The Plan says IRF care 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 your nursing, medical, and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. The medical records do not support that you would meet criteria for admission to an 
acute inpatient rehabilitation facility. You can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services billed with codes 83520 and 87798 for 
January 16, 2023. 
 
You asked the Plan to pay for codes 83520 and 87798. You say that this should be reprocessed. The Plan 
denied your request. The Plan says these Not Otherwise Classified (NOC) codes were not billed with 
descriptions of the specific tests performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that when billing for unlisted laboratory tests using a Not Otherwise Classified (NOC) code, field 19 of the claim must include the specific 
name of the laboratory tests or a short descriptor of the tests. 
 
In this case, the CPT Code Manual definition of code 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of 87798 is 
infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism. 
 
We find that CPT code 83520 and 87798 is not supported in the medical record. Specifically, these are NOC 
codes that were not billed with a name or description of the tests in field 19 of the claim. Based on this 
information, we decided that Medicare rules for coverage of codes 83520 and 87798 have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory services billed with codes 83520 and 
87798 for January 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from June 9, 2023, through 
June 21, 2023. 
 
You asked the Plan to pay for inpatient hospital care . You say that the provider was unable to properly assist 
you and you were unaware of the copayment for inpatient care. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $360 
copayment per day for days 1 through 5 for covered hospital care. 
 Review of the file shows that you were admitted on June 9, 2023, and discharged on June 21, 2023. You were 
asked to pay a $360 copayment per day from June 9, 2023, through June 13, 2023, days 1-5 of your inpatient 
stay. There were no copayment charges from June 14, 2023, day 6 of your inpatient hospital care until your day 
of discharge June 21, 2023. Per your contract there is a $360 copayment per day required for days 1-7. This 
item/service falls within the Inpatient Hospital Care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for 
inpatient hospital care provided from June 9, 2023, through June 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing billed with codes 87481, 87491, 87500, 
87563, 87640, 87641, 87653, and 87798 for date of service May 13, 2023. 
 
You asked the Plan to pay for the laboratory testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a provider/supplier shall not report multiple 
HCPCS/CPT codes if a single HCPCS/CPT code exists that describes the services. This type of unbundling is 
incorrect coding. 
 
 
 We looked at the file and Medicare rules. Review of the file shows that the services were billed individually 
instead of the appropriate panel code. The codes are not individually payable as billed. 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 laboratory testing billed with codes 87481, 
87491, 87500, 87563, 87640, 87641, 87653, and 87798 for date of service May 13, 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 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306,81328, 81335, 81479, 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you are requesting a redetermination of 
the denial and have enclosed documentation to substantiate the claim. 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 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306,81328, 
81335, 81479, 81238.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76882 billed for date of service April 25, 
2023. 
 You asked the Plan to pay for procedure code 76882. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 76882 is bundled into payment for code 93971. 
 
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 76882 
is a column II code to column I code 93971. 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 76882 billed for date of service April 25, 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 you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has 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 rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement, however, the documentation 
does not  support that he would meet criteria for admission to an acute inpatient rehabilitation facility. The 
enrollee can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 12, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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 lab services provided on May 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 27, 2023, billed with 
codes 87532, 87496, 87798, 87486, 87581, 87640, 87541, and U0005. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's 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 27, 2023, billed with codes 87532, 87496, 87798, 87486, 87581, 87640, 87541, and U0005.