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

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service October 25, 
2022.   
You asked the Plan to pay for procedure code 88342. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88342 is 4. The MAI value for this code is 3. You billed 5 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88342 have not been met.  Therefore, we decided that the 
Plan does not have to pay for procedure code 88342 billed for date of service October 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 0241U billed for date of service 
December 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that you billed a payable code and diagnosis. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 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. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 0241U 
billed for date of service December 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 87507 for date of service 
December 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 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. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 87507 
for date of service December 15, 2022.
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 February 15, 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 
February 15, 2023.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 77063-26. We decided that 
the Plan does not have to pay for the services described by procedure code(s) 77067-26 x2.  
 
You asked the Plan to pay for imaging services provided on January 23, 2023, billed with code 77067-26 x2. 
You say that the claim is billed correctly and should be paid. The Plan says that the units billed exceeds 
Medicare MUE allowed. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 77063-26.  
 
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) 77063-26.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
77067-26 x2. 
 
The Plan follows Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds 
the MUE value cannot be paid when the MAI value is 2.  
 
We looked at this physician's review, the file, and Medicare rules. In this case, the MUE for CPT code 77067 is 
1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this 
information, we decided that Medicare rules for coverage of the services described by procedure code(s) 
77067-26 x2 have not been met. Therefore, we decided that the Plan does not have to pay for the services 
described by procedure code(s) 77067-26 x2. 
 
 
 
 
 
 
 
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88177 billed for date of service August 9, 
2022.  You asked the Plan to pay for procedure code 88177. You say that these services were reported correctly. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88177 is 6. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88177 have not been met.  Therefore, we decided that the 
Plan does not have to pay for procedure code 88177 billed for date of service August 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like the Plan to reconsider their 
denial of payment. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023, to January 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 73502 billed for date of service December 24, 2022. 
 
You asked the Plan to pay for code 73502. You say that this was an emergency service and it should be paid. 
The Plan denied your request. The Plan says this code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that STV-packaged services are services for which 
separate payment is made only if there is no service with status indicator S, T, or V reported on the same claim. 
If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- 
packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) 
with status indicator S, T, V and no separate payment is made for the STV-packaged service. STV-packaged 
services are assigned status indicator Q1. In this case, the code in dispute has a status indicator of QI, meaning 
that it is a STV-packaged service.  This disputed code was billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the code in dispute in this appeal is not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 73502 have not been met. Therefore, we decided that the Plan does not have to pay for code 
73502 billed for date of service December 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 2, 2022, to 
October 31, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you believe this claim was billed 
correctly. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from October 2, 2022, to 
October 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar radiofrequency ablation (RFA) (64636, 
64635). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the requested items/services are not 
considered medically reasonable and necessary in this case. The Plan denied your request. The Plan says under 
Medicare guidelines, the service requested does not meet the requirements for approval and is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgical procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the LCD criteria requires 80% pain relief to be documented from both sets of 
diagnostic blocks.  This was not achieved.  Further, the presence of ongoing radiculopathy precludes the 
performance of RFA of the medial branches as per the criteria of the LCD. Therefore, the request is deemed 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 surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the lumbar radiofrequency ablation (RFA) (64636, 64635).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic testing (81479) provided 
December 27, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you request reconsideration of the original 
determination and coverage of the GeneSight Psychotropic test as medically necessary. The Plan denied your 
request. The Plan says medical necessity cannot be established. 
 
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 the laboratory service have been met. 
additional records were requested from the provider without success. Therefore, we decided that the Plan does 
not have to pay for the GeneSight Psychotropic testing (81479) provided December 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service January 6, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that multiple tests were needed in the course of 
the patient's treatment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve block rendered on April 14, 2021. 
 
You asked the Plan to pay for the block. You say that this was medically necessary. The Plan denied your 
request. The Plan says the clinical value and effectiveness of a genicular nerve block in the setting of knee 
osteoarthritis has not been demonstrated in the peer-reviewed literature. 
 
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 block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. The review has determined that the genicular nerve blocks are considered experimental/ 
investigational in nature. 
 
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 block have not been met. Therefore, we decided that the Plan does not have 
to pay for a genicular nerve block rendered on April 14, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
November 11, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that you originally billed another 
insurance as patients primary due to member providing incorrect insurance information at time of visit. The 
Plan denied your request. The Plan says the claim was untimely, and the submission did not meet the 
exception criteria guidelines outlined in 42 CFR Section 424.44.  
 
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 record shows that a claim for the emergency department visit was not filed until December 6, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit provided on 
November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 16, 2022, billed with 
codes 81225 and 81226. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. 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 
May 16, 2022, billed with codes 81225 and 81226.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of permanent pacemaker. 
 
You asked the Plan to pre-approve insertion of permanent pacemaker. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that implanted permanent single chamber or dual chamber 
cardiac pacemakers are covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve insertion of permanent pacemaker. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the evidence 
provided would not meet criteria for pacemaker implant. . In summary, there is insufficient documentation to 
support the medical necessity for the requested cardiac pacemaker in this enrollees 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 insertion of permanent pacemaker have not been met. Therefore, we decided 
that the Plan does not have to pre-approve insertion of permanent pacemaker.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services billed with code 99284 
for December 25, 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 the claim was not billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with mismatched laterality diagnosis codes. 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 emergency room 
(ER) services billed with code 99284 for December 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 provided on November 3, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 76641 is not supported in the medical record. Specifically, two units were billed on 
separate claims with RT and LT laterality modifiers. This code has a bilateral indicator of 1. This code should 
be billed using modifier 50 (bilateral). Based on this information, we decided that Medicare rules for coverage 
of procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 provided on November 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGx Hereditary Cancer Panel provided on December 6, 
2022, and billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 
81314, 81334, 81345, and 81272. 
 
You asked the Plan to pay for the CGx Hereditary Cancer Panel. You say that this testing was medically 
necessary.  The Plan denied your request. The Plan says this test 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 CGx Hereditary Cancer Panel have not been met. Therefore, we decided that the Plan does not have to pay for the CGx Hereditary Cancer Panel 
provided on December 6, 2022, and billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 
81317, 81321, 81351, 81209, 81314, 81334, 81345, and 81272.