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

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 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 claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 the laboratory services rendered on 
May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 1, 2023, to 
February 28, 2023, billed with procedure codes 29445-LT and 11042. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 29445-LT and 11042 is application of rigid total contact 
leg cast, and debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or 
less. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the medical record does not include a 
procedure report for services billed. Therefore, the billed procedures 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 the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on February 1, 2023, to February 28, 2023, 
billed with procedure codes 29445-LT and 11042.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 17, 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 claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 the laboratory services rendered on 
May 17, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on February 17, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the 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. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) rendered on February 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73725 billed for date of service June 29, 
2023. 
 
You asked the Plan to pay for procedure code 73725. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says procedure code 73725 is considered bundled and not 
separately payable.  
 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 73725 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 73725 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 73725 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 73725 billed for date of service June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel provided January 17, 2023, billed with 
codes 87640, 87481, 87798 x13, 87653, 81003, 87086. 
 
You asked the Plan to pay for the laboratory testing. You say that please reconsider this claim for 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a 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 testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel provided 
January 17, 2023, billed with codes 87640, 87481, 87798 x13, 87653, 81003, 87086.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
December 2, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the test panel was not billed as a single unit of 
service. 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 the urine polymerase chain reaction (PCR) 
panel rendered on December 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on December 27, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the coding of this claim is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS) code.  
 
We looked at the file and Medicare rules. This testing was billed with POS code 81, indicating an independent 
laboratory setting. However, the record does not support that the sample was taken directly in the independent 
laboratory. Based on this information, we decided that Medicare rules for coverage of genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on December 
27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services described by code 64447 performed on 
date of service June 7, 2023. 
 
You asked the Plan to pay for 64447. You say that 64447 should be paid as billed because this service was 
performed to treat post-procedural pain was not included in any other service reported on the same date. The 
Plan denied your request. The Plan says 64447 is denied because it is not supported in the documentation and 
was billed on the same date as code 01402. 
 
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 64447 is injection(s), anesthetic agent(s) and/or steroid; 
femoral nerve, including imaging guidance, when performed. 
 We find that CPT code 64447 is not supported in the medical record. Specifically, the provided record does not 
include documentation of a post-procedural injection being given. Based on this information, we decided that 
Medicare rules for coverage of 64447 have not been met. Therefore, we decided that the Plan does not have to 
pay for the injection services described by code 64447 performed on date of service June 7, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on January 30, 
2023. 
 You asked the Plan to pay for the paramedic intercept services. You say that you would like reconsideration 
because the requested paramedic intercept is medically necessary. The Plan denied your request. The Plan says 
this service is not a covered benefit. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept services provided on January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically 
ill or critically injured patient for each additional 30 minutes (List separately in addition to code for primary 
service) provided July 31, 2023. 
 You asked the Plan to pay for the critical care services. You say that the primary procedure 99291 was billed 
under a different physician. The Plan denied your request. The Plan says the primary code of 99291 was not 
billed for the same date of service being appealed.  
 
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 the 
critical care services is an add-on code and has not been billed with an appropriate primary procedure code. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the critical care, evaluation and management of the critically ill or critically injured 
patient for each additional 30 minutes (List separately in addition to code for primary service) provided July 
31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 19, 2023, to 
March 22, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that  
diagnosis code G93.49 (Encephalopathy NEC) was accurately reported and billed with the appropriate DRG. 
The Plan denied your request. The Plan says that the medical records did not have sufficient documentation to 
clinically validate diagnosis code G93.49 (Encephalopathy NEC). Therefore, code G93.49 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with G93.49 (Encephalopathy NEC). 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 hospital services at the DRG originally billed. 
Our physician reviewer found that there is no clear documentation that encephalopathy was present beyond the 
patient's baseline dementia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 19, 2023, to March 22, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271), Carboplatin (J9045), Doxorubicin 
Hydrochloride Liposome (Q2050), Dexamethasone IV (J1100), and Netupitant/Palonosetron IV (J1454). 
 
You asked the Plan to pre-approve Keytruda, Carboplatin, Doxorubicin Hydrochloride Liposome, 
Dexamethasone IV, and Netupitant/Palonosetron IV. 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. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda, Carboplatin, Doxorubicin 
Hydrochloride Liposome, Dexamethasone IV, and Netupitant/Palonosetron IV. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested drugs are not FDA-approved 
for the enrollees diagnosis with the progression on prior immunotherapy. The use is not supported by one of 
the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Carboplatin, Doxorubicin Hydrochloride Liposome, Dexamethasone 
IV, and Netupitant/Palonosetron IV have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Keytruda (J9271), Carboplatin (J9045), Doxorubicin Hydrochloride Liposome (Q2050), 
Dexamethasone IV (J1100), and Netupitant/Palonosetron IV (J1454).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortic aneurysm (AAA) screening (76706) 
provided on January 4, 2023. 
 
You asked the Plan to pay for the AAA. You say that this should be covered. The Plan denied your request. 
The Plan says the benefit for this service has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the AAA have not been met. Therefore, we decided that the Plan does not have to pay for the 
abdominal aortic aneurysm (AAA) screening (76706) provided on January 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing provided January 5, 2023, billed 
with codes 87801-90 X3, 87798-90 XU X12, 87653-90 XU, 87481- 90, 87150-90 XU X12. 
 
You asked the Plan to pay for the laboratory testing. You say that kindly review the attached documents and 
process this claim towards possible 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Also, the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture 
and sensitivity. 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 Urine PCR panel 
testing provided January 5, 2023, billed with codes 87801-90 X3, 87798-90 XU X12, 87653-90 XU, 87481- 
90, 87150-90 XU X12.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiology (heart transplant), mRNA gene profiling of 30 
genes (81595) provided on June 30, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory service. You say that you request a reversal of the denial and 
coverage of the claim for AlloMap Heart. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 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 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 cardiology (heart transplant), mRNA gene 
profiling of 30 genes (81595) provided on June 30, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2023 to July 15, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2023 to July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telephone evaluation and management service provided on 
June 07, 2023. 
 
You asked the Plan to pay for telephone evaluation and management service. You say that you are requesting 
reconsideration for the denied claim. 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 June 07, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22850-80-58-XS rendered on June 12, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 22850 is considered inclusive to CPT 22840. 
 
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 22850 is "Removal of posterior nonsegmental 
instrumentation (eg, Harrington rod)."  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support 22850 
as a separate and distinct procedure. It is included in 22840 and cannot be unbundled. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 22850-80-58-XS rendered on June 12, 2023.