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

 
We decided that the Plan does not have to pay for procedure codes 81226, 81240, 81241, 81328, 81225, 81227, 
81231, 81232, 81306, and 81335 for date of service March 4, 2023. 
 
You asked the Plan to pay for procedure codes 81226, 81240, 81241, 81328, 81225, 81227, 81231, 81232, 
81306, and 81335. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be 
considered part of the 
same panel. 
 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 testing panel have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 81226, 81240, 
81241, 81328, 81225, 81227, 81231, 81232, 81306, and 81335 for date of service March 4, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services described by code 01710, billed on date of 
service June 15, 2023. 
 
You asked the Plan to pay for 01710. You say that 01710 should be paid as billed because it is supported in the 
record and is unrelated to any other procedure on the same date of service. The Plan denied your request. The 
Plan says that 01710 is denied because it is included in the payment for code 01844 which was billed on the 
same date of service by a provider of the same billing group and same specialty. 
 
The Plan must follow Medicare rules. Medicare rules say that payment can be made for anesthesia services 
associated with multiple surgeries. The rules also say that providers in the same group practice, of same 
specialty, treating the same enrollee on the same date of service must bill and be paid as though they were a 
single provider, unless the services provided by each are for unrelated problems.  
 
We looked at the file and Medicare rules. The Plan has applied the multiple anesthesia payment rule to these 
two practitioners of the same specialty from the same group practice based on the rule indicating that such 
providers bill and are paid as a single provider. However, this rule from Chapter 12, Section 30.6.5 of the 
Medicare Claims Processing Manual allows for exceptions. In this case, these two practitioners treated the 
same enrollee on the same date of service; however, one was for anesthesia related to condition T82.838A, 
defined as hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounter, and the other 
was anesthesia related to condition N18.6, defined as end stage renal disease. As such, these practitioners 
treated the enrollee for unrelated problems and are not required to bill and be paid as a single provider. For this 
reason, we determined that standard anesthesia fee schedule payment should be made for the services at issue. 
Based on this information, we decided that Medicare rules for coverage of 01710 have been met. Therefore, we 
decided that the Plan has to pay for the anesthesia services described by code 01710, billed on date of service 
June 15, 2023.  
 
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: 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 needs physical and occupational therapy. 
You also say that the enrollee had colonoscopy surgery and has a colostomy bag to wear for six months to a 
year. The Plan denied your request. The Plan says the enrollee's chronic medical conditions do not require the 
expertise of a rehabilitation physician in an IRF setting.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for surgical management of a diverticular abscess. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical 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 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 genetic testing provided on June 5, 2023, billed with 
codes 81225, 81226, 81227, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that please find the attached appeal and 
process the claim towards payment. 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. Also, the tests performed have not been cleared or approved by the FDA. 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 June 5, 2023, 
billed with codes 81225, 81226, 81227, 81240, 81241, 81291, 81306, 81328, 81335, 81479, and 81238.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 for date of service April 9, 2023. 
 
You asked the Plan to pay for procedure code 99239. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation did not 
include a hospital discharge day management note for the billed date of service. Based on this information, we decided that Medicare rules for coverage of procedure code 99239 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 99239 for date of service April 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on June 9, 2023 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on June 9, 2023
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal testing (81479) provided on July 26, 2023. 
 
You asked the Plan to pay for Guardant Reveal testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is 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. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Guardant Reveal testing have not been met. Therefore, we decided that the Plan 
does not have to pay for Guardant Reveal testing (81479) provided on July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection panel billed with codes 87640, 
87481, 87798, and 87653 for date of service January 12, 2023. 
 
You asked the Plan to pay for the urinary tract infection panel billed with codes 87640, 87481, 87798, and 
87653. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Review of the file shows that the services at issue are a panel and 
were billed individually. The codes are not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of the urinary tract infection panel billed with codes 87640, 87481, 87798, and 
87653 have not been met. Therefore, we decided that the Plan does not have to pay for the urinary tract 
infection panel billed with codes 87640, 87481, 87798, and 87653 for date of service January 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
September 12, 2022, and billed with codes 87640, 87481, 87798, 87653, 81003, and 87086. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing 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 urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on September 12, 2022, and billed with codes 87640, 87481, 87798, 87653, 81003, and 87086.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Invitae Beast Cancer 1and 2 (BRCA1/2) panel (81433) 
provided June 23, 2023.  
 
You asked the Plan to pay for the laboratory testing. You say that based on the provided information and the 
physician's decision to order the test, you are requesting coverage at this time for the claim. The Plan denied 
your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The Invitae BRCA1/2 panel (81433) is not covered by Medicare per 
DEX diagnostics and is not approved. The requested genes for the Invitae BRCA1/2 Panel (81433) are already 
included in the Multi-Cancer panel (81432) which is duplicative and not expected to give additional 
information separate from the approved test. Based on this information, we decided that Medicare rules for 
coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the Invitae Beast Cancer 1and 2 (BRCA1/2) panel (81433) provided June 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service August 2, 
2023. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0480. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
 
In this case, we have confirmed that code 83789 is a column II code to column I code G0480. While code 
83789 was billed with modifier -59 the medical records provided do not show that the service billed with the -
59 modifier is a distinct procedural service. 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 83789 billed for date of 
service August 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 24, 2023, and May 25, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service July 1, 
2007, and after, the non-Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be 
integrated into the OPPS OCE. This integration will result in the routing of all institutional outpatient claims, 
including non-OPPS hospital claims, through a single integrated OCE eliminating the need to update two 
separate OCE software packages on a quarterly basis. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with code G0378 on two separate claim lines. This returned OCE edit 51, which denies these claim lines, as well as the rest of the claim. Based 
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the services provided on May 24, 2023, and May 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
August 15, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing 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 urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on August 15, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for an expandable controller (E2377), harness
(E2313), and electronic connection (E2311).

You asked the Plan to provide coverage for these accessories. The Plan denied your request. The Plan says the
Medicare criteria for these accessories were not met. Maximus overturned the Plans denial. The Plan requested
a reopen and stated that Maximus did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable
controller (E2377), harness (E2313), and electronic connection (E2311). The Maximus Physician Reviewer
determined that the complexity of the enrollee's seating and positioning needs necessitates a more complex
Group 3 power wheelchair base. "The expandable controller with harness and electronic connection are
necessary to operate the Group 3 power wheelchair base and the three power options, including, tilt, recline and
elevating leg rests, via a joystick. Therefore, the reviewer found that the upgraded electronics, made up of an
expandable controller (E2377) with harness (E2313) and electronic connection (E2311), are medically
necessary." The Plan requested a reopen and stated the upgraded electronics are not medically necessary in this
case.

The medical records show you are a 69-year-old man with right sided hemiplegia due to a gunshot wound to
the head. You are unable to ambulate and are unable to self-propel a manual wheelchair. The current power
wheelchair is due for replacement. You are independent with eating, grooming, hygiene, and general daily
activities and your left upper extremity is functional.

The Plan is correct in this case. The clinical documentation supports that the left upper limb strength and
function are adequate for you to control the power options using their own switches. The expandable controller
(E2377), harness (E2313), and electronic connection (E2311) are 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 these accessories have not been met. Therefore, we decided that the Plan does not have to provide
coverage for an expandable controller (E2377), harness (E2313), and electronic connection (E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87653 billed for date of service March 23, 
2023.  You asked the Plan to pay for procedure code 87653. You say that these services were medically necessary. 
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 87653 is 1. The MAI value for this code is 3. You billed 2 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 87653 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87653 billed for date of service March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on July 13, 2023. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test was medically necessary and 
appropriate. The Plan denied your request. The Plan says this test is 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. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on July 13, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan (78814). 
 
You asked the Plan to pre-approve the PET scan. You say that the services should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says that the criteria for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our physician reviewer 
found that the included neuropsychic testing demonstrated findings consistent with both frontotemporal 
degeneration (FTD) and Alzheimers disease (AD). Given that a clinical diagnosis cannot be differentiated on 
exam alone, in as much the use of a PET scan would be considered to be consistent with standards of care in 
this setting to differentiate between the two diagnoses and permit a conclusion.  
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan (78814).  
 
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.