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

 
We decided that the Plan does not have to pre-approve an office visit (99214), therapeutic radiology 
simulation-aided field setting; complex (77290), therapeutic radiology simulation-aided field setting; simple 
(77280) and a high dose rate electronic brachytherapy, skin surface application, per fraction, includes basic 
dosimetry (0394T). 
 
You asked the Plan to pre-approve an outpatient procedure. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says a review of the current medical literature 
shows that the evidence is insufficient to determine long-term efficacy and safety data to support the routine 
use of electronic surface brachytherapy. 
 
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 outpatient procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the electronic surface brachytherapy is not necessary and is not considered a standard 
of care for enrollees with a such type of skin cancer. 
 
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 outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an office visit (99214), therapeutic radiology simulation-aided field setting; 
complex (77290), therapeutic radiology simulation-aided field setting; simple (77280) and a high dose rate 
electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry (0394T).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87900. We decided that the Plan does not have to pay 
for procedure codes 87481, 87640, 87652 and 87798.  

You asked the Plan to pay for procedure codes 87481, 87640, 87652, 87798 and 87900 billed for date of 
service January 12, 2023. You say that these services were necessary and are supported in the medical record. 
The Plan says that these services are not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We decided that the Plan has to pay for procedure code 87900.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 87900. Our reviewer says that this code is 
supported in the medical record. Our reviewer found that the laboratory report describes drug susceptibility and 
therefore code 87900 is supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 87900 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87900.  
 
We also decided that the Plan does not have to pay for procedure codes 87481, 87640, 87652 and 87798. 
 
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 87481, 87640, 87652 and 87798. Our 
reviewer says that these codes are not supported in the medical record. Our reviewer found the laboratory 
report does not include documentation of candida species, amplified probe technique, streptococcus, group A, 
quantification, staphylococcus aureus, or infectious agent detection. These procedures cannot be verified as 
they are not found in the laboratory report. 
 
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 87481, 87640, 87652 and 87798 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87481, 87640, 87652 and 87798. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64493 and 64494 billed for date of service 
November 30, 2022. 
 
You asked the Plan to pay for procedure codes 64493 and 64494. You say that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says the operative report does not include 
enough documentation to support these services. 
 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 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 64493 and 64494. Our reviewer says that 
the codes at issue are not supported in this case. Our reviewer found the record does not support the use of CPT 
codes 64493 and 64494. The record states that a nerve block was performed at the sacroiliac joint. This is 
included in the procedure code which was already approved. 
 
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 64493 and 64494 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 64493 and 64494 billed for date of service November 
30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641 and 87653 billed for 
date of service November 9, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641 and 87653. You say that these services 
were reported appropriately and are supported in the medical record. The Plan denied your request. The Plan 
says these services are not supported for separate payment. 
 
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 codes 87150, 87481, 87641 and 87653 are column II codes to column I 
codes 87500 and/or 87801; however, 87150, 87481, 87641 and 87653 were each billed with a modifier.  
 
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 87150, 87481, 87641 and 87653. Our 
reviewer says that the XU modifier is not supported for these codes. Our reviewer found the laboratory report 
does not include documentation to support that these services are unusual non-overlapping services, and 
therefore separate reporting cannot be verified. 
 
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 87150, 87481, 87641 and 87653 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641 and 87653 billed for 
date of service November 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation code P9603 billed for date of service October 
26, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were submitted. The Plan 
denied your request. The Plan says the billed code cannot be verified. 
 
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 P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
We find that CPT code P9603 is not supported in the medical record. Specifically, the records do not show that 
the round-trip travel was more than 20 eligible miles or that travel was to more than one location. 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 transportation code P9603 billed for date of service October 
26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 hours of psychological testing (96131, 96130). 
 
You asked the Plan to pre-approve 5 hours of psychological testing. 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 5 hours of psychological testing Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found it is unclear how the services being requested are 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 5 hours of psychological testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 5 hours of psychological testing (96131, 96130).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 23, 2022, to 
February 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. 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 January 23, 2022, to 
February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 23, 2022. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare will automatically deny claim line(s) items 
submitted with a GZ modifier.  
 
We looked at the file and Medicare rules. The claim is denied because it was billed with the -GZ modifier. 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64415 billed for date of service September 9, 
2022. 
 You asked the Plan to pay for procedure code 64415. The Plan denied your request. The Plan says payment for 
code 64415 is bundled into payment for code 01630. 
 
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 64415 
is a column II code to column I code 01630. 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 64415 billed for date of 
service September 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service November 
25, 2022. 
 You asked the Plan to pay for procedure code 99497. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 99497 is bundled into 
payment for code 99223. 
 
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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service November 25, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 13, 2022, to 
April 11, 2022. 
 You asked the Plan to pay for the home health services. You say that you originally filed the NOA timely with 
Original Medicare. 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 January 12, 2022. The NOA was not received by the Plan until July 6, 
2022. You were required to file this NOA with the Plan, not with Original Medicare. 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 March 13, 2022, to April 
11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair or non-routine service for DME other than 
oxygen equipment requiring the skill of a technician, labor component, per 15 minutes (K0739) and 
miscellaneous durable medical equipment (DME) (E1399). 
 
You asked the Plan to pre-approve the continuous positive airway pressure (CPAP) repairs. You say that you 
are appealing the denial based on medical necessity. The Plan denied your request. The Plan says the enrollee's 
CPAP is 7 years old and has exceeded reasonable useful lifetime. 
 
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 records show that the enrollee's CPAP machine which was 
purchased on June 18, 2016. The CPAP is 7 years old and has exceeded reasonable useful lifetime, therefore 
repairing with replacement parts is not reasonable and necessary. Medicare covers repairs for approved devices 
for up to 5 (five) years. Based on this information, we decided that Medicare rules for coverage of the 
continuous positive airway pressure (CPAP) repairs have not been met. Therefore, we decided that the Plan 
does not have to pre-approve repair or non-routine service for DME other than oxygen equipment requiring the 
skill of a technician, labor component, per 15 minutes (K0739) and miscellaneous durable medical equipment 
(DME) (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87653 and 87481 billed for date of service 
October 26, 2022. 
 
You asked the Plan to pay for procedure codes 87653 and 87481. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says these services are not supported for separate 
payment. 
 
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 codes 87653 and 87481 are column II codes to column I code 87801. Code 
87481 has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met for code 87481. However, code 87481 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 87653. Our reviewer says that the XU 
modifier is not supported with this code. Our reviewer found the laboratory report does not include 
documentation of to show that this procedure is unusual and non-overlapping. Therefore, this code and 
modifier XU cannot be verified. 
 
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 87653 and 87481 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87653 and 87481 billed for date of service October 26, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 17, 2022, billed with 
codes 81162, 81307, 81321, 81351, 81407 and 81408. 
 
You asked the Plan to pay for the genetic testing billed. 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. 
 
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 
August 17, 2022, billed with codes 81162, 81307, 81321, 81351, 81407 and 81408.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2011 billed for date of service March 2, 
2023. 
 
You asked the Plan to pay for procedure code H2011. You say that you have weekly services with this provider 
due to mental health severe outburst. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 We find that procedure code H2011 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2011 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H2011 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2011 billed for date of service March 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 28, 2022, to 
February 25, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that it was unclear that the Plan was 
going to require NOAs.  As soon as you learned an NOA was required, it 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 January 28, 2022, to 
February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 billed for date of service October 25, 
2022. 
 You asked the Plan to pay for procedure code 87481. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87481 is bundled into payment for code 87801. 
 
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 87481 
is a column II code to column I code 87801. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and 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 87481 billed for date of service October 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on February 20, 2023, billed with 
procedure code 93971-26-RT. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers or suppliers shall use anatomic 
modifiers and report procedures with differing modifiers on individual claim lines when appropriate. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the imaging services provided have not been met. This claim was billed with diagnosis code 
R22.42, described as localized swelling, mass and lump, left lower limb which is not appropriate for lines with 
modifier RT (right) appended.  Therefore, we decided that the Plan does not have to pay for imaging services 
provided on February 20, 2023, billed with procedure code 93971-26-RT.