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

 
We decided that the Plan does not have to pay for procedure code 72131-26-XP billed for date of service 
February 17, 2023.  
 
You asked the Plan to pay for procedure code 72131-26-XP. You say that codes 72131 and 72132 were 
separately performed and medically necessary procedures. The Plan denied your request. The Plan says 
payment for code 72131-26-XP is bundled into payment for code 72132-26. 
 
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 72131-26-XP is a column II code to column I code 72132-26 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 72131-26-XP billed for date of 
service February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on January 5, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that the ordering 
physician determined that this testing was medically necessary for the enrollee. The Plan denied your request. 
The Plan says ordering a multi-class panel of definitive (confirmation) urine drug tests that are not used in 
clinical management, exceeds the needs of the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that definitive drug testing is covered when the criteria in 
the rules section of this letter are met.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
medical record sent by the provider shows a definitive UDT panel for multiple drug classes was performed but 
does not show screening test results which are positive or inconsistent with prescription medications, dosing 
schedules, or history and expected results. The review has determined that the enrollee does not meet the LCD 
criteria for coverage. 
 
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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on January 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for medical services provided on March 10, 2023. 
 
You asked the Plan to pay for the medical services. You say that the patient was seen by separate providers on 
this date of service. The Plan denied your request. The Plan says you billed this claim with an incorrect Place 
of Service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead. 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the methyenetetrahydrofolate reductase (MTHFR) (81231) 
and pharmacogenomic panel (0345U) provided March 15, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that you request reconsideration of the denied 
services. The Plan denied your request. The Plan says the records do not support that the service is medically 
reasonable or 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 pay for the 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 diagnosis of major depression. Per Medicare LCD 
indications for testing includes: The provider performing the service must have a record of what drug(s) is/are 
being considered and for what reason(s) to ensure the test performed is reasonable and necessary. In this case, 
the drugs being considered have previously failed, hence testing for same drugs for therapeutic intervention is 
not reasonable or necessary. The review has determined that the items/services at issue in this case are 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 the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the methyenetetrahydrofolate reductase (MTHFR) (81231) and pharmacogenomic panel 
(0345U) provided March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99326 billed for date of service February 4, 
2022. 
 You asked the Plan to pay for procedure code 99326. You say that you do not believe this code needs to be 
billed with a modifier. The Plan denied your request. The Plan says payment for code 99326 is bundled into 
payment for code 99327. 
 
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 99326 
is a column II code to column I code 99327. 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 99326 billed for date of service February 4, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 12, 2022, to 
November 7, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim was denied due to missing 
value code 85. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
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 start of care date is October 12, 2022. The NOA was not received by the Plan until December 
10, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, 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 October 12, 2022, to November 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
March 31, 2023 and April 6, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services in this case were not rendered on 
the basis of a covered diagnosis.  
 
 
 
  
 
 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to pay for the acupuncture treatments (97810, 97811) provided on March 31, 2023 and April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Varithena. 
 
You asked the Plan to pre-approve Varithena. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 Varithena. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Varithena is not standard of care for the enrollee's condition and 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 Varithena have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Varithena.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease (DJD) or foramainal stenosis. The cause of the pain is not clear.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20610, 77002 and J7328 billed for date of 
service November 2, 2022. 
 
You asked the Plan to pay for procedure codes 20610, 77002 and J7328. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the provided records do not support the 
codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 20610, 77002 and J7328 are not supported in the medical record. Specifically, a 
procedure report for the date of service at issue has not been provided. Based on this information, we decided 
that Medicare rules for coverage of procedure codes 20610, 77002 and J7328 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 20610, 77002 and J7328 billed for date of 
service November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307, 83789 and G0480 billed for date of 
service April 27, 2023. 
 
You asked the Plan to pay for procedure codes 80307, 83789 and G0480. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the provided records do not support the 
services billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, the provided 
test order does not specify the drug classes intended for testing. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 80307, 83789 and G0480 have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 83789 have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable.  
 
Therefore, we decided that the Plan does not have to pay for procedure codes 80307, 83789 and G0480 billed 
for date of service April 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional trips are 
necessary. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 50 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 28470 is not supported. 
 
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 code 28470 is 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 28470 is closed treatment of metatarsal fracture; without 
manipulation, each. 
 
We find that CPT code 28470 is not supported in the medical record. Specifically, there is no detailed operative 
note of a closed treatment of metatarsal fracture without manipulation. 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 code 28470 is not supported.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided from June 20, 2022, to June 21, 
2022. 
 
You asked the Plan to pay for the inpatient stay. The Plan denied your request. The Plan says coverage for 
acute inpatient level of care is denied. The Plan also says it does not meet the definition of medical necessity. 
 
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 the inpatient stay. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record did not show that at the time of inpatient admission the admitting physician 
reasonably expected that your necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient stay provided from June 20, 2022, to June 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 16, 2023, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 8147, 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you believe the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your 
request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code.  
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 16, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 8147, 81238.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided from March 1, 2023, to May 
9, 2023, by an OON provider.  
 
You asked the Plan to pay for the podiatry services. You say that the provider is in-network with the Plan. The 
Plan denied your request. The Plan says the provider is not in-network, and the services were not authorized. 
 
 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 Plan contract says the enrollees POS benefit only applies to 
nonMedicare covered dental services covered by the plan. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the podiatry services provided from March 1, 
2023, to May 9, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone evaluation and management service provided on 
January 03, 2023. 
 
You asked the Plan to pay for telephone evaluation and management service. You say that the services 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 telephone evaluation and 
management service provided on January 03, 2023.