Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service October 17, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service October 17, 2022, billed 
with code 99153.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service December 15, 2022, billed with codes 99152 and 99153. 
 
You asked the Plan to pay for procedure codes 99152 and 99153. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says codes 99152 and 99153 is not payable 
in the facility setting.  
 Medicare rules say that the OPPS recognizes that CPT codes 99152 and 99153 are PE only codes and that PE 
are not payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT codes 99152 and 99153 is not supported. Specifically, there is no separate 
payment to the physician for CPT codes 99152 and 99153 when performed in the facility setting. Therefore, we 
decided that the Plan does not have to pay for the additional moderate sedation time provided on date of service 
December 15, 2022, billed with codes 99152 and 99153.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 58578 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 58578. You say that this service was reported correctly. The Plan 
denied your request. The Plan says this service is not supported in the medical record. 
 
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 58578 is unlisted laparoscopy procedure, uterus. 
 
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 procedure code 58578. Our reviewer says that this code is 
not supported in this case. Our reviewer found the record states that a trachelectomy was performed. There is a 
more specific code for this procedure. According to CPT guidelines, an unlisted code shall not be used if a specific code exists. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 58578 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 58578 billed for date of service August 30, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 8, 
2023. 
 You asked the Plan to pay for procedure code 99285. You say that this service should be paid.  The Plan denied 
your request. The Plan says payment for code 99285 is bundled into payment for code 99284. 
 
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 99285 
is a column II code to column I code 99284, which was billed by another emergency medicine specialist in the 
same billing group. 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 99285 billed for date of service January 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infrared light therapy provided from May 3, 2022, to  
August 16, 2022. 
 
You asked the Plan to pay for Infrared light therapy. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Infrared therapy is considered not reasonable and necessary by 
Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. 
 We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for Infrared light therapy provided from May 3, 2022, to August 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
December 6, 2022, to December 8, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says the information submitted shows that the enrollee was 
admitted to the hospital for slurred speech. There was no documentation of an acute stroke.  
 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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee has a history of hypertension and breast cancer who presented with 
unintelligible speech upon standing to go to the commode after awakening during sleep. The workup did not 
support stroke/cerebrovascular accident or other serious acute condition. The enrollee was given intravenous 
(IV) fluids, Norvasc, letrozole, and Protonix. Swallow was normal and the enrollee was given regular diet with 
IV fluids later discontinued. The enrollee was hemodynamically stable on admission. The enrollee did not have 
a serious acute condition or complex conditions this presentation. There was no expectation that the enrollee 
would require hospital services that would likely cross two midnights due to the stability of the enrollee.  
 
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 pay for the acute inpatient hospital care provided from December 6, 2022, to  
December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm or disorder, 51 or greater genes (81455) provided December 2, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that experimental procedures are not covered 
under the Plan. The Plan denied your request. The Plan says you are requesting an appeal of the 
FoundationOne Heme comprehensive genomic profiling 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 the enrollee in this case has a diagnosis of recurrent metastatic malignant neoplasm 
of lower respiratory tract (synovial sarcoma). FoundationOne Heme comprehensive genomic profiling test was 
performed and is being requested for coverage. This test is designed to help decide potential targeted therapy 
options for acute myelogenous leukemia (AML), myelodysplastic syndromes (MDS), and myeloproliferative 
neoplasms (MPN). However, the enrollee does not have any of these conditions and current literature does not 
support this test benefits patients with synovial sarcoma in terms of an improved overall outcome to support 
this test for this enrollee at this time. Therefore, without sufficient high-quality evidence to support this test for 
this clinical situation, the FoundationOne Heme comprehensive genomic profiling test will be considered not 
medically necessary at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the targeted genomic sequence analysis panel, solid organ or hematolymphoid 
neoplasm or disorder, 51 or greater genes (81455) provided December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service August 8, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service August 8, 2022, billed 
with code 99153.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the spring powered device (A4258) for diabetic testing provided on 
July 20, 2022.  
 
You asked the Plan to pay for the A4258 device. You say that it is felt this should be covered.  The Plan denied 
your request. The Plan says that this cannot be provided more than once every six months. 
 
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. The Plan did not provide evidence to support the denial rationale in this case. 
Without documentation that the device (A4258) was provided within the six months prior to the date of service, 
the denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for the spring 
powered device (A4258) for diabetic testing provided on July 20, 2022.   
 
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 pre-approve genetic testing (Decisiondx-melanoma) (81529). 
 
You asked the Plan to pre-approve genetic testing. You say that the enrollee does meet medical criteria per the 
LCD and Medicare guidelines which included the enrollee having a T1A with several adverse features such as 
a Breslow of 0.6, radial and vertical growth present, and present peripheral margins. The Plan denied your 
request. The Plan says the requested testing 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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not meet criteria for the requested genetic testing. The reviewer agrees with 
the determination of the previous reviewer that the tumor does not have required features. Testing is not 
medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (Decisiondx-melanoma) (81529).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection and identification, targeted 
sequence analysis (16s and 18s rRNA genes) with drug-resistance gene (0112U) provided January 11, 2023. 
 
You asked the Plan to pay for genetic testing. You say that the procedure codes you have billed are reasonable 
and necessary. The Plan denied your request. The Plan says this service is not medically necessary and not 
standard of care.  
 
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 genetic testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a history of retained calcified ureteral stent, right 
hydronephrosis and spina bifida and has had multiple stones in the past. The enrollee also has a history of 
neurogenic bladder. The enrollee has been managing this with self-catheterization daily from spina bifida. 16s 
rRNA sequencing is a culture-free method to identify and compare bacterial diversity from complex 
microbiomes or environments that are difficult to study. It is commonly used to identify bacteria present within 
a given sample down to the genus and/or species level. This test is not considered the standard of care. The 
review has determined that the items/services at issue in this case were not medically reasonable or 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 genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for infectious agent detection and identification, targeted sequence analysis (16s and 18s rRNA 
genes) with drug-resistance gene (0112U) provided January 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0671) to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says this item is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (E0652, E0671) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93572 provided on June 3, 2022. 
 
You asked the Plan to pay for procedure code 93572. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed service. 
 
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 93572 is Doppler velocity and/or pressure derived 
coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including 
pharmacologically induced stress; each additional vessel. 
 
We find that CPT code 93572 is not supported in the medical record. Specifically, the procedure report 
provided does not describe this service was performed. Based on this information, we decided that Medicare rules for coverage of procedure code 93572 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 93572 provided on June 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has difficulty walking without 
assistance. You feel if the enrollee is discharged to home, they will not be able to care for themself. You also 
say the enrollee will need occupational therapy, physical therapy, and speech therapy. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare guidelines for services in an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute 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, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service January 17, 
2023.  
 You asked the Plan to pay for procedure code 76641. You say that the patient had multiple exams on this date 
of service. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
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 billed for date of 
service January 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377 and 88381 
billed for date of service May 10, 2022. 
 You asked the Plan to pay for procedure code(s)  88341, 88342, 88360, 88377 and 88381. You say that these 
services were billed correctly. The Plan denied your request. The Plan says these codes are included in the 
facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
88377 and 88381. This means there is both a professional and technical component for the CPT code(s). In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s)  
88341, 88342, 88360, 88377 and 88381. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 88341, 88342, 88360, 88377 and 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377 and 88381 billed for date 
of service May 10, 2022.