Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 17, 2022, to 
April 15, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted this claim and NOA timely 
to Original Medicare. The Plan denied your request. The Plan says the NOA was not received timely. As such, 
this final claim was correctly denied.  
 
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. Please note that although you may have submitted 
your NOA to Original Medicare, you did not submit it to the Plan timely as is required. 
 
In this case, the start of care date is January 16, 2022. The NOA was not received by the Plan until September 
19, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, 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 March 17, 2022, to April 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 9 additional units of procedure code 88307 rendered on 
August 23, 2022. 
 You asked the Plan to pay for the additional units. You say that this should be paid for. The Plan denied your 
request. The Plan says that while the documentation does support that the excess units were provided, there is 
no specific rationale as required by the policy as to why additional units needed to be 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. 
 
In this case, the CPT Code Manual definition of code 88305 is "Level V - Surgical pathology, gross and 
microscopic examination." 
 
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 for the additional units. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provided records in this case 
consist of a surgical pathology report on a breast lump biopsy, breast tissue, and sentinel lymph nodes. The 
provided records do not show any support that it was medically necessary to perform 17 units of this service - 9 
units over the usual Medically Unlikely Edits (MUE). 
 
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 additional units have not been met. Therefore, we decided that the Plan does 
not have to pay for 9 additional units of procedure code 88307 rendered on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service December 
26, 2022. 
 You asked the Plan to pay for procedure code 99222. The Plan denied your request. The Plan says payment for 
code 99222 is bundled into payment for code 99223. 
 
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 99222 
is a column II code to column I code 99223. 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 99222 billed for date of service December 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on February 7, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this molecular pathology 
testing is not payable with code 81479. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. Additionally, DEX Diagnostic Exchange 
indicates which codes are payable for the requested testing. 
 
We looked at the file and Medicare rules. The Plan has provided evidence from the DEX database that the 
MolDX recommended code for the Guardant360 testing with the Z-code reported is 0326U, and that 81479 is 
not listed as an appropriate code for the testing. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
testing provided on February 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 January 27, 2022, to 
February 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that there is a NOA on file, so this 
claim should be reprocessed. 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 January 27, 2022, to 
February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with codes 64483-LT and 64484-
LT/59 billed for January 24, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says payment is included in the ambulatory surgical center (ASC) payment. 
 
The Plan must follow Medicare rules. The rules say that under the ASC payment system, Medicare makes 
facility payments to ASCs only for the specific ASC covered surgical procedures on the ASC list of covered 
surgical procedures. 
 
We looked at the file and Medicare rules. The file shows that billed codes 64483-LT and 64484-LT/59 are 
included in the approved procedures for APC payment and are not separately payable beyond the packaged 
payment. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services billed with codes 
64483-LT and 64484-LT/59 billed for January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is a covered service and was medically 
necessary. 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 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 8, 2022, billed 
with codes 81314 and 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and should be paid. 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 
November 8, 2022, billed with codes 81314 and 81345.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 27, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (TTE). 
 
You asked the Plan to pre-approve the requested TTE. You say that the enrollee has had an abnormal 
electrocardiogram which supports the need for TTE. The Plan denied your request. The Plan says there has 
been no clinical status change or new signs and symptoms to warrant this testing.  
 
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 requested TTE. Our reviewer says 
that the requested TTE is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a male with no cardiac symptoms noted with a history of previous TTE. The 
documentation does not point to a change in status that would support the medical necessity of a TTE at this 
time. Clinical guidelines do not support repeating a TTE with no intervening change in clinical status or new signs, symptoms or physical findings. In summary, there is no supportive evidence for the medical necessity of 
a TTE in this enrollee's 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 the requested TTE have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a transthoracic echocardiogram (TTE).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the elective procedure, right total hip 
replacement, has been approved. The procedure is not on the CMS inpatient only list. The preoperative 
clearance and comorbid conditions suggest that the procedure could initially be performed on an 
ambulatory/observation basis. There is no need to prospectively approve the inpatient admission. 
 
 
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient hospital care is met in this 
case. Our physician reviewer found the record indicates that you are scheduled for a total hip arthroplasty. The 
record provided does not indicate that the treating physician has a reasonable expectation of a length of stay 
spanning 2 or more midnights, taking into account complex medical factors. The initial day may be spent in 
observation until it is clearly expected that a second midnight would be required, at which time the physician 
may order inpatient admission. The elements of the coverage criteria are not satisfied. The requested service is 
not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 2, 2022 to 
August 9, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration of DRG adjustment. The Plan denied your request. 
The Plan says a post-service, post-payment clinical and coding validation audit was performed to help ensure 
that the diagnosis codes on the claim supported clinically. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 689. 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 hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee was started on fluids and antibiotics; however, mental status did not appear to improve with 
treatment. As there didn't seem to be a connection with the urinary tract infection (UTI) or any other metabolic 
disease causing her mental status changes, the code, G93.41, metabolic encephalopathy, is not sufficiently 
supported as a secondary diagnosis. Therefore, the more appropriate DRG would be 690 for this admission 
based on the provided documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 2, 2022 to August 9, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services rendered on January 24, 
2023. 
 
You asked the Plan to pay for the services. You say that there are no additional claims that could cause this 
denial. The Plan denied your request. The Plan says this service is included in the global package. 
 
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 99824 is not supported in the medical record. Specifically, the same provider rendered a major surgery (CPT 27520) on October 27, 2022, as well as the emergency department services on January 24, 
2023. An appropriate modifier was not reported for CPT 99284 that would indicate that it was a separate and 
distinct procedure from the surgery. CPT 99284 cannot be reported separately within the global period without 
the appropriate modifier. 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 
department services rendered on January 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 4, 2022, to 
March 5, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA and 
believe this claim should be reprocessed. The Plan denied your request. The Plan says the NOA was not 
received timely. As such, this final claim was correctly denied.  
 
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 start of care date is January 5, 2022. The NOA was not received by the Plan until March 10, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, 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 February 4, 2022, to March 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medical need for the multiple power options included with the requested 
K0861 group 3 power wheelchair with multiple power options. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee has a neurological disorder with functional deficits. The documentation does 
indicate any pressure injuries or a need for intermittent catheterization of the bladder. There is no spasticity that 
would necessitate power tilt or recline. The criteria for this specific wheelchair has not been met. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair with multiple power options.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging/radionuclide stress 
testing (78451). 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says no doctor's notes were sent. 
 
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 imaging. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation that the electrocardiogram (ECG) shows an uninterpretable pattern or that 
the enrollee is unable to exercise. There is no evidence provided that would support the need for radionuclide 
stress testing at this time. In summary, there is insufficient documentation to support the medical necessity for 
the requested cardiac stress testing in this enrollee's 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 the imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial perfusion imaging/radionuclide stress testing (78451).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service November 
14, 2022. 
 
You asked the Plan to pay for procedure code 95941. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service November 14, 2022.