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

 
We decided that the Plan does not have to pay for the TEN antibiotic resistance panel and urine PCR 
(polymerase chain reaction) panel. 
 
You asked the Plan to pay for the laboratory tests. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says these tests are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. We looked at the file and Medicare rules. These tests are not listed in the DEX database as having completed a 
technical assessment and being eligible for coverage. Based on this information, we decided that Medicare 
rules for coverage of the laboratory tests have not been met. Therefore, we decided that the Plan does not have 
to pay for the TEN antibiotic resistance panel and urine PCR (polymerase chain reaction) panel.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you, along with the enrollee's other 
attending physicians have determined that the enrollee is stable and now suitable for transfer to long term acute 
care. You also say that it is your opinion that the enrollee cannot be adequately cared for at a skilled nursing 
facility, and requires the level of care they will receive at the specialty hospital. The Plan denied your request. 
The Plan says the criteria for an LTACH admission have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with acute on chronic hypoxemic respiratory failure 
secondary to chronic obstructive pulmonary disease exacerbation in the setting of chronic kidney disease. The 
record indicates that the enrollee has ongoing acute medical issues and still requires acute care services. Our 
reviewer found that the enrollee continues to receive acute care services, and these have not been denied. Our 
physician reviewer also found that the medical record does not indicate that the enrollee requires services that 
they are not currently receiving but that would be available at the LTACH facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27447-79 billed for date of service April 3, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the modifier was appended due to being in the 
post operative period. The Plan denied your request. The Plan says the modifier was not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 27447-79 is not supported in the records. The case file does not include claim 
information or other documentation to show that the code billed with the -79 modifier was provided during the 
global surgical period of a previous procedure. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 27447-79 billed for date of service April 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 17, 2022, to August 
15, 2022. 
 You asked the Plan to pay for the home health services. You say that the original NOA was submitted in 2021. 
The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied. The Plan says that although your appeal indicates that a NOA was submitted, none has been received. 
 
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 NOA was not received by the Plan. As a result, 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 July 17, 2022, 
to August 15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on May 12, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says two of the billed 
diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that M54.50 has an Excludes1 note in relation to S39.012D. This means that 
the two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the services have not been met. Therefore, we decided that the Plan does not have to pay for 
the therapy services provided on May 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport and ground mileage services 
provided on March 30, 2023. 
 
You asked the Plan to pay for the ambulance transport and ground mileage services. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that K92.0 has an Excludes1 note in relation to R11.0. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the ambulance transport and ground mileage services have not been met. Therefore, we decided that 
the Plan does not have to pay for the ambulance transport and ground mileage services provided on March 30, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service May 22, 
2023.  
 
You asked the Plan to pay for procedure code 81456. The Plan denied your request. The Plan says payment for 
code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not payable. 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 81456 billed for date of service May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 1, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the patient clearly requires an LTACH 
level of care and is stable for discharge to that level of care per their team of physicians. The Plan denied your 
request. The Plan says based on Medicare guidelines, the LTACH services requested do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient was admitted with lower extremity necrotizing fasciitis and required 
operative intervention. The record indicates that the patient has ongoing acute medical issues and still requires 
acute care services. Our reviewer found that the patient continues to receive acute care services, and these have 
not been denied. Our physician reviewer also found that the medical record does not indicate that the patient 
requires services that they are not currently receiving but that would be available at the LTACH facility. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0242U) provided on March 29, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed date of 
service is incorrect. 
 
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 payment for CPT code 0242U is not supported in the medical record. Specifically, the records 
show that the specimen was collected on March 15, 2023. The claim should be billed with the date that the 
specimen was collected. As such, code 0242U is not supported for the billed date of service. 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 the lab services (0242U) provided on March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 9, 2023, billed with 
procedure code 95165 (24 units). 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support number of units 
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 95165 (24 units) is professional services for the 
supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens 
(specify number of doses). 
 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found the medical documentation does not 
support 24 units. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on January 9, 2023, billed with procedure code 
95165 (24 units).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on June 22, 2023, billed with 
codes 87481, 87500, 87563, 87640, 87641, 87653 and 87798. The Plan also does not have to pay for procedure 
code 87491. 
 
You asked the Plan to pay for the laboratory testing billed and for procedure code 87491. You say that you 
have billed the services at issue correctly. The Plan denied your request. The Plan says panel testing should be 
billed using one CPT code on the claim. Additionally, the provided records do not support procedure code 
87491. 
 
The Plan must follow Medicare rules. The rules say that providers must report services correctly. The rules also 
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. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing 
billed have not been met. 
 
We find that CPT code 87491 is not supported in the medical record. Specifically, the provided physician order 
does not contain a request for the testing denoted by code 87491. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87491 have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory testing provided on June 22, 2023, billed with codes 87481, 87500, 
87563, 87640, 87641, 87653 and 87798. The Plan also does not have to pay for procedure code 87491.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel billed for date of service May 31, 2023, 
with codes 87500, 87556, 87641, 87653 and 87798. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the laboratory panel billed for date of service May 31, 2023, with codes 87500, 87556, 87641, 87653 and 
87798.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has both medical complexity and 
functional criteria that meet the guidelines for admission to an IRF. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for admission to 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 12, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no bundling issue 
with these codes. 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 
12, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  Durolane. 
 You asked the Plan to pre-approve Durolane. You say that the medication is appropriate and medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed one 
of the preferred medications. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Durolane. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the documentation does not outline 
contraindications or reasons why Monovisc, Orthovisc, Synvisc or Synvisc-One have not been considered or 
that they would likely be less effective or have adverse effects for the enrollee. Durolane is not approved as 
step criteria 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve  Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Orthotic. 
 
You asked the Plan to pre-approve a MyoPro Orthotic. You say that the requested MyoPro Orthotic is 
medically necessary. The Plan denied your request. The Plan says the requested MyoPro Orthotic 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 a MyoPro Orthotic. Our reviewer says 
that the requested MyoPro Orthotic is not medically necessary. Our physician reviewer found current clinical 
guidelines for adult stroke rehabilitation and recovery designate robotic therapy to be of "uncertain utility 
compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home 
environment.  
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 MyoPro Orthotic have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro Orthotic.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for May 20, 2023. 
 
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 billed diagnoses are not appropriate. 
 
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 procedure code 99232 was billed with diagnosis 
codes that exclude each other. Therefore, we decided that the Plan does not have to pay for procedure code 
99232 billed for May 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection (87506) billed for date of service 
March 24, 2022. 
 
You asked the Plan to pay for infectious agent detection (87506). You say that the specimens were received 
from providers who perform intraoperative biopsies and must be processed without delay to avoid spoilage. 
You say that the claim should be paid in full. The Plan denied your request. The Plan says there is a more 
appropriate code for the services rendered. 
 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), 
includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple 
types or subtypes, 6 to 11 targets. 
 
We find that CPT code 87506 is not supported in the medical record. Specifically, the CPT code billed is for 6 
to 11 targets. However, the records support more than 11 targets. Based on this information, we decided that 
Medicare rules for coverage of infectious agent detection (87506) have not been met. Therefore, we decided 
that the Plan does not have to pay for infectious agent detection (87506) billed for date of service March 24, 
2022.