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

 
We decided that the Plan does not have to pay for the definitive drug testing of 22 or more drug classes 
provided on April 19, 2023.  
 
You asked the Plan to pay for the definitive drug testing. You say that this was medically necessary testing.  
The Plan denied your request. The Plan says the order does not specify the number of drugs classes to be 
tested. As such, it cannot be confirmed that 22 or more classes were intended by the ordering provider.  
 
The Plan must follow Medicare rules. Medicare rules say that there must be an order for lab testing.  
 
We looked at the file and Medicare rules. While the file does contain a requisition for "Urine MCT (All-in-
One), marked as number 329, there is no documentation to support this test is for 22 or more drug classes. 
Without a specific order for this number of classes, we cannot confirm that this testing was provided as 
ordered. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing of 
22 or more drug classes provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99204) rendered on June 8, 
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 records do not support the services 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 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter." 
 
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 records did not support 45-59 
minutes of total time spent on this encounter. The records did not support CPT 99204 as a significant and 
separately identifiable evaluation and management service from CPT 95911 and CPT 95886. 
 
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 an office visit (procedure code 99204) rendered on June 8, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service April 20, 
2023. 
 You asked the Plan to pay for procedure code 76770. You say that this service is not bundled and should be 
paid. The Plan denied your request. The Plan says payment for code 76770 is bundled into payment for code 
93976. 
 
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 76770 
is a column II code to column I code 93976. 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 76770 billed for date of service April 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 5, 2022, to May 4, 
2022. 
 You asked the Plan to pay for the home health services. You say that this claim was filed timely. 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 April 5, 2022. The NOA was not received by the Plan until June 29, 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 
April 5, 2022, to May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ConfirmMDx test (81551) provided February 21, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are appealing the denial of ConfirmMDx 
for prostate cancer. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested test. 
 
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 it appears that the ConfirmMDx was ordered before considering a second biopsy 
based on prostate-specific antigen (PSA) levels or digital rectal exam (DRE) exam. The test was not ordered in 
the pre-biopsy phase to determine the need for the second biopsy. It was also not ordered after the second 
biopsy in the post-biopsy phase when considering another repeat biopsy due to concerns of rising PSA or 
abnormal DRE. 
 
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 ConfirmMDx test (81551) provided February 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99344 rendered on April 20, 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 Current Procedural Terminology (CPT) code 99344-25 (1 Unit) 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 99344 is "Home or residence visit for the evaluation and 
management of a new patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making. When using total time on the date of the encounter for code selection, 60 
minutes must be met or exceeded." 
 
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, or that 60 
minutes were spent on the service. 
 
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 99344 rendered on April 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 11, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing should be 
billed with one code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure.  
 
We looked at the file and Medicare rules. The testing in this case was billed with multiple codes. Per Medicare 
rules, the genetic testing should be billed with one unit of one code. 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 genetic testing provided on April 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 8, 2022, to July 7, 
2022. 
 You asked the Plan to pay for the home health services. You say that the payment for this claim should be 
reduced, not denied in full. 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 June 8, 2022. The NOA was not received by the Plan until January 30, 
2023. 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 June 8, 2022, to July 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0481 for date of service May 3, 2023. 
 
You asked the Plan to pay for code G0481. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed 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 G0481 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the submitted medical 
records do not include an order for drug test(s), definitive 8-14 drug classes; therefore, the billed service cannot 
be verified. Based on this information, we decided that Medicare rules for coverage of code G0481 have not 
been met. Therefore, we decided that the Plan does not have to pay for code G0481 for date of service May 3, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on January 12, 2022, and 
February 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the claim for January 12, 2022, was received untimely. The Plan also says the services 
received on February 23, 2022, are non-covered services. 
  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The Plan also offers a dental benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows that the claim for the dental services provided on January 12, 2022, was not filed until March 
8, 2023. This means that more than one calendar year from the date of service had passed before a claim was 
filed. In addition, the services provided on February 23, 2022, are not covered benefits. Therefore, we decided 
that the Plan does not have to pay for the dental services provided on January 12, 2022, and February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88188 billed for date of service December 
22, 2022. 
 You asked the Plan to pay for procedure code(s) 88188. The Plan denied your request. The Plan says this code 
is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
A PC/TC indicator of 2 identifies stand-alone codes that describe the physician work portion of selected 
diagnostic tests for which there is an associated code that describes the technical component of the diagnostic 
test only and another associated code that describes the global test. Modifiers 26 and TC cannot be used with 
these codes. Code 88188 is assigned a PC/TC indicator of 2. As such, it is inappropriate to billed. Based on this 
information, we decided that Medicare rules for coverage of procedure code 88188 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code(s) 88188 billed for date of service 
December 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration and have 
provided medical records for review. The Plan denied your request. The Plan says the request is not medically 
necessary because the records show that the ordered settings for the ventilator show it is going to be used in a 
bi-level pressure mode. The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has obesity 
hypoventilation syndrome, severe obesity, obstructive sleep apnea, hypertension, heart failure with preserved 
ejection fraction (HFpEF), and atrial fibrillation. The enrollee was hospitalized in July 2023, after a fall at 
home, suffering three rib fractures. Arterial blood gases (ABGs) showed acute on chronic hypercarbic 
respiratory failure, and the enrollee required intubation. There is no diagnosis of COPD, thoracic restrictive 
disease, or neuromuscular disease. There is no documentation of chronic carbon dioxide (CO2) retention with 
an ABG done while stable. If that is present, the enrollee may benefit from BiPAP during sleep as an 
outpatient. The records do not show BiPAP has been tried and failed as an outpatient. Medicare does not cover 
a home ventilator for the treatment of obesity hypoventilation syndrome, or when used at settings that can be 
provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on March 10, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says there is a more 
appropriate code for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure.  
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple codes. Per 
Medicare rules, the panel should be billed with one unit of one code. Based on this information, we decided 
that Medicare rules for coverage of the panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab panel provided on March 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 5, 2022, to 
January 3, 2023. 
 You asked the Plan to pay for the home health services. You say that you mailed your original NOA timely, but 
due to the timing of the mail process, you didn't learn that the NOA was invalid until January 6, 2023. You said 
that you resubmitted a corrected NOA on January 10, 2023. 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 December 5, 2022. The NOA was not received by the Plan until January 
10, 2023. 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 December 5, 2022, to January 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84439 and 84481 billed for date of service 
December 12, 2022. 
 
You asked the Plan to pay for procedure codes 84439 and 84481. You say that these tests were medically 
necessary and appropriate. The Plan denied your request. The Plan says the records do not support that these 
specific tests/codes were requested by the enrollee's physician for testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of procedure codes 84439 and 84481 
have been met. the physician order provided does not list these two tests as requested. The order instead lists a 
few panels which would be reported with panel codes. The records do not support these tests as billed. 
Therefore, we decided that the Plan does not have to pay for procedure codes 84439 and 84481 billed for date 
of service December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) provided October 4, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit.  
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 service. Our reviewer found CPT code 
99223 (1 unit) was not supported. This initial hospital care evaluation and management code requires a 
comprehensive history, a comprehensive examination and medical decision making of high complexity. In this 
case, the medical records submitted did not support a comprehensive history and medical decision making of 
high complexity. The records supported a comprehensive examination. 
 
We looked at this physician reviewer's review, the file, and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan 
does not have to pay for initial hospital care (99223) provided October 4, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
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 supports that the criteria for inpatient admission are met in this case. Our 
physician reviewer found based on the presentation, initial workup, the enrollee was expected to require 
hospital care that would have likely crossed 2 midnights. The enrollee is still in the hospital being treated.  
 
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 been met. Therefore, we decided that the Plan 
has to pre-approve the acute inpatient hospital care.  
 
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.