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

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 14, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service January 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee has shown that they are 
no longer capable of being adequately supported by BiPAP therapy. The Plan denied your request. The Plan 
says a home ventilator is not medically necessary for this patient because their needs can be met with an 
alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).   
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 system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has chronic hypercapnic respiratory failure from chronic obstructive pulmonary disease and can be treated with 
a BiPAP machine with AVAPS capability. However, failure of such a device has not been documented. Also, 
the documentation does not contain sufficient detailed information in the medical records to justify the 
treatment selected. Therefore, the elements of the coverage criteria are not satisfied, and the requested services 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found you have age related osteoporosis without osteoporotic fracture. The documentation does not support 
that you have tried and failed one oral bisphosphonate (such as alendronate, risedronate) and one intravenous 
bisphosphonate therapy (such as zoledronic acid). The documentation does not support that one oral 
bisphosphonate and one intravenous bisphosphonate therapy would likely be less effective and/or likely have 
adverse effects. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient lab services provided on March 11, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient laboratory tests are generally 
packaged as ancillary services and do not receive separate payment. 
 
We looked at the file and Medicare rules. In this case, payment for the requested outpatient laboratory services 
is included in the outpatient hospital base rate. The lab services are not separately payable. 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 outpatient lab services provided on March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87798-XU, 87640-XU, 87653-XU, 
and 87481-XU provided on May 22, 2023. 
 You asked the Plan to pay for procedure codes procedure codes 87150, 87798-XU, 87640-XU, 87653-XU, and 
87481-XU. You say that the medical records support the procedure codes as billed. The Plan denied your 
request. The Plan says the medical records do not support the procedure codes as billed. 
 
Medicare rules say while a physician order is not required to be signed, the physician must clearly document, in 
the medical record, the intent that the test be performed.  
 
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 codes procedure codes 87150, 87798-XU, 87640-
XU, 87653-XU, and 87481-XU. Our reviewer says that the medical records do not support the procedure codes 
as billed. Our reviewer found the services in question were not reported in accordance with Medicare rules. 
Medicare requires an order listing specific tests to be performed. The records submitted do not contain an order 
listing what tests are to be performed. This does not meet coverage requirements. 
 
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 codes procedure codes 87150, 87798-XU, 87640-XU, 87653-XU, 
and 87481-XU have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 87150, 87798-XU, 87640-XU, 87653-XU, and 87481-XU provided on May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes Q0092 and R0070 billed for May 11, 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 procedure codes Q0092 and R0070 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 Q0092 is set-up portable x-ray equipment. The definition 
of code R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to 
facility or location, one patient seen. 
 
We find that CPT codes Q0092 and R0070 are not supported in the medical record. Specifically, the records do 
not contain documentation of set up of portable x-ray equipment to support code Q0092. The records do not 
contain documentation of transportation of portable x-ray equipment to support code R0070. 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 procedure codes Q0092 and R0070 billed for May 11, 2023.
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 enrollee requires a multidisciplinary 
approach to help manage medically complex issues. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for LTACH admission. 
 
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 does not require services at the LTACH that are not already available at 
the current facility. Completion of treatment at the current facility is recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from April 19, 2023, to April 25, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provide is not 
eligible to enroll in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the services provided from April 19, 
2023, to April 25, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued occupational therapy visits (97165). 
 
You asked the Plan to pre-approve continued therapy visits. You say that additional occupational visits are 
medically necessary for the enrollee.  The Plan denied your request. The Plan says the provided records do not 
support that the enrollee meets the medically necessary criteria for continued occupational visits  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee had a stroke and has persistent weakness in the right arm. 
The enrollee has had 19 of 20 sessions and is dependent on activities of daily living as the enrollee cannot use 
the right arm. There is no indication or rationale provided for continued therapy in setting of previous therapy. 
The enrollee has limited function and continued gains after 3 months of therapy is not expected based on 
clinical outcome of a stroke. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued occupational therapy visits (97165).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (85048) provided on January 5, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and are 
separately payable. The Plan denied your request. The Plan says the payment for these services is included in 
the payment to the skilled nursing facility where the enrollee was being covered by Part A Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the payment for laboratory services provided to a 
Medicare beneficiary enrolled in a Part A covered SNF stay is included in the payment to the SNF facility.  
 
We looked at the file and Medicare rules. The enrollee was in a Part A covered inpatient SNF stay at the time 
of services. This means that the payment for these services would be included in the payment to the SNF 
facility and would be paid by the facility under arrangements to the laboratory. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (85048) provided on January 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87491, 87563, 87640, 87653, 87798, 
87641 and 87500 billed for April 23, 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 codes 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 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique. The definition of code 87491 is infectious agent 
detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique. The definition of 
code 87563 is infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified 
probe technique. The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique. The definition of code 87653 is infectious agent detection 
by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. The definition of code 
87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. The definition of code 87641 is infectious agent detection by nucleic acid (DNA or 
RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 87500 is 
infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species 
van A, van B), amplified probe technique. 
 
We find that CPT codes 87481, 87491, 87563, 87640, 87653, 87798, 87641 and 87500 are not supported in the 
medical record. Specifically, a panel was performed and there is a more appropriate single code for the 
services. 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 procedure codes 87481, 87491, 87563, 
87640, 87653, 87798, 87641 and 87500 billed for April 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cough stimulating device (E0482) and suction pump 
(E0600) provided on January 29, 2023, to February 28, 2023. 
 
You asked the Plan to pay for a cough stimulating device (E0482) and suction pump (E0600). You say that the 
items were medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a cough stimulating 
device (E0482) and suction pump (E0600) provided on January 29, 2023, to February 28, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96374 billed for date of service May 23, 
2023. 
 You asked the Plan to pay for procedure code 96374. The Plan denied your request. The Plan says payment for 
code 96374 is bundled into payment for code G0498. 
 
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 96374 
is a column II code to column I code G0498. 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 96374 billed for date of service May 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 26, 2023, billed with 
codes 87481, 87491, 87500, 87563, 87640, 87641, 87653 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 26, 2023, billed with codes 87481, 87491, 87500, 87563, 87640, 87641, 87653 and 
87798.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 71046, defined as x-ray of chest, 2 views, performed on 
date of service May 28, 2023. 
 
You asked the Plan to pay for 71046. You say that 71046 should be covered because it was medically 
necessary. The Plan denied your request. The Plan says 71046 is denied because the diagnosis billed does not 
meet Medicare National Coverage Determination (NCD) or Local Coverage Determination (LCD) criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the written or electronic request for chest 
radiography should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation. When billing a chest x-ray, diagnosis code Z01.818 does 
not support medical necessity of the x-ray. 
 
We looked at the file and Medicare rules. We confirmed that in this case, procedure code 71046 was billed with 
diagnosis code Z01.818, defined as encounter for other preprocedural examination, only. Per LCA A57497, 
diagnosis code Z01.818 does not support medical necessity. It is required to provide sufficient information to 
demonstrate medical necessity when billing a chest x-ray. Based on this information, we decided that Medicare 
rules for coverage of 71046 have not been met. Therefore, we decided that the Plan does not have to pay for 
code 71046, defined as x-ray of chest, 2 views, performed on date of service May 28, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is at a very high risk for 
readmission, deterioration, and even death if discharged to a lower level of care. You say it is not necessary for 
the enrollee to remain in the short term acute care hospital when all required services and treatments can be 
managed at the LTACH level of care. The Plan denied your request. The Plan says based on the clinical 
information received, the enrollee does not meet the guidelines for LTACH services.  
 
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 that there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. Given there are offered alternatives, LTACH 
is not medically 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 18, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service January 18, 2023.