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

 
We decided that the Plan does not have to pay for 13 units of procedure code 93010 rendered on December 9, 
2022. 
 You asked the Plan to pay for the additional units. You say that this should be paid for. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations, as there was no 
specific rationale given for why additional units needed to be performed. 
 
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 93010 is "Electrocardiogram, routine ECG with at least 
12 leads; interpretation and report only." 
 
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 additional units. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found that at issue was the 
appropriateness and medical necessity of performing 13 ECG studies in one day in the clinical management of 
the enrollee. The documentation is not provided showing a rationale for carrying out all of these studies. Eight 
of the ECGs are available for review. Several show non-specific ST-segment and T-wave (ST-T) changes and 
prolonged QT interval. No arrhythmias are noted, nor evidence to support an acute ST elevation myocardial 
infarction or even acute ischemia.  In summary, there is no documentation to support the need to perform 13 
separate studies. 
 
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 additional units have not been met. Therefore, we decided that the Plan does 
not have to pay for 13 units of procedure code 93010 rendered on December 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS cytopathology and histopathology diagnostic 
testing (88112, 88305, 88312, 88361) provided on July 20, 2022.  
 
You asked the Plan to pay for the WATS cytopathology and histopathology diagnostic testing. You say that 
there is no documentation or history of Barrett's esophagus, dysplasia, or concerns of a precancerous/cancerous 
process. The Plan denied your request. The Plan says this testing was medically 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 WATS cytopathology and 
histopathology diagnostic testing. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the record indicates that the 
enrollee has gastroesophageal reflux disease without esophagitis. There is insufficient literature to support the 
safety and efficacy, as defined by Medicare rules, of the requested service. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied.  
 
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 WATS cytopathology and histopathology diagnostic testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the WATS cytopathology and histopathology 
diagnostic testing (88112, 88305, 88312, 88361) provided on July 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 14, 2022, to 
July 12, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you believe this claim was been 
billed correctly. 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 June 14, 2022, to July 
12, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituxan. 
 You asked the Plan to pre-approve Rituxan. 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 covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Rituxan. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that you have tried and failed the required drugs. There is no indication that the plan's 
required drugs would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Rituxan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that the requested 
genicular nerve radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says 
the requested genicular nerve radiofrequency ablation is not medically 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 pre-approve genicular nerve radiofrequency 
ablation. Our reviewer says that the requested genicular nerve radiofrequency ablation is not medically 
necessary. Our physician reviewer found this procedure is the subject of ongoing clinical trials.  Therefore, the 
request is deemed, at this time, not medically reasonable and 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 genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
from September 2, 2022, to September 23, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that this item was medically 
necessary based on medical literature and the efficacy of the treatment rendered. The Plan denied your request. 
The Plan says this service does not meet this requirement of the enrollee's plan of benefits and is excluded from 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0217 is provided it will be denied as not 
reasonable and necessary. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided from September 2, 2022, 
to September 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from November 2, 2022, to 
November 28, 2022. 
 You asked the Plan to pay for the home health services. You say that you have provided the required NOA. 
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 November 2, 2022. The NOA was not received by the Plan until February 
1, 2023. 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 November 2, 2022, to November 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided on July 11, 2021 to July 
14, 2021, 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 this 
should be paid for. The Plan denied your request. The Plan says a post-service, post-payment coding and 
clinical audit was performed to help ensure that the diagnosis codes on the claim are 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 diagnosis code F10.139 (Alcohol abuse with 
withdrawal, unspecified). 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 reviewer says that the services at issue in this case were not 
supported by the medical records. Our physician reviewer found that based on the medical records provided 
there is no support for diagnosis code F10.139 (Alcohol abuse with withdrawal, unspecified) as the primary 
diagnosis for the hospitalization. The enrollee had a history of heart failure, chronic lung disease and alcohol 
abuse presented with abdominal distention, increased edema, and dyspnea in the setting of medication non-
compliance; he was treated with intravenous Lasix and improved. Based on the enrollee's signs, symptoms and 
treatment provided, the most appropriate primary diagnosis was heart failure.  
 
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 July 11, 2021 to July 14, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 3, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for astigmatism correcting function of intraocular lens (V2787) 
and femtosecond laser for astigmatic correction (A9270) provided February 22, 2023.  
 
You asked the Plan to pay for the vision services. You say that you were told that you had glaucoma and 
cataracts and while having this surgery, you were told they will put a stent in to relive the buildup of pressure 
and if you didn't you could go blind. The Plan denied your request. The Plan says these services are not 
covered by Medicare or the Plan. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Also, the claim was billed with CPT code A9270 which indicates a non-covered 
item or service. Therefore, we decided that the Plan does not have to pay for astigmatism correcting function of 
intraocular lens (V2787) and femtosecond laser for astigmatic correction (A9270) provided February 22, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 18, 2022, 
to March 19, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the Plan has not provided you 
with an exact denial reason for this claim. 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 February 18, 2022, to 
March 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 24576 and 99285 provided on October 5, 
2022. 
 
You asked the Plan to pay for procedure codes 24576 and 99285. You say that the medical records support the 
billing of codes 24576 and 99285.  The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 24576 and 99285.  
 
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 24576 is Closed treatment of humeral condylar fracture, 
medial or lateral; without manipulation. The definition of code 99285 is Emergency department visit for the 
evaluation and management of a patient, which requires these 3 key components within the constraints imposed 
by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of 
high severity and pose an immediate significant threat to life or physiologic function. 
 
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 24576 and 99285. Our reviewer says that 
the medical records do not support the billing of codes 24576 and 99285.  Our reviewer found the review 
indicates that the enrollee was evaluated in the emergency department on October 5, 2022, for a left forearm 
injury. Current Procedural Terminology (CPT) code 24576-LT (1 Unit) was not supported. The medical 
records submitted did not indicate restorative treatment was performed to support closed treatment of humeral 
condylar fracture, medial or lateral, without manipulation. Current Procedural Terminology (CPT) code 99285-
57 (1 Unit) was not supported. This emergency department evaluation and management code requires a 
comprehensive history, a comprehensive examination and medical decision making of high complexity. In this 
case, the medical records submitted did not support a comprehensive history and medical decision making of 
high complexity. 
 
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 24576 and 99285 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 24576 and 99285 provided on October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88104 billed for date of service January 10, 
2023. 
 You asked the Plan to pay for procedure code 88104. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 88104 is bundled into payment for code 88112. 
 
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 88104 
is a column II code to column I code 88112. 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 88104 billed for date of service January 10, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 21, 2022, to 
March 22, 2022. 
 You asked the Plan to pay for the home health services. You say that the Plan has not told you the exact reason 
for denial of this claim. The Plan denied your request. The Plan says the required NOA was not received. 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 22, 2022. You have not submitted a valid NOA for this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from February 21, 
2022, to March 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 19, 2022, to May 
18, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim was billed correctly. 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 March 20, 2022. The NOA was not received by the Plan until December 7, 
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 April 19, 2022, to May 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 28, 2022, to 
February 26, 2022. 
 You asked the Plan to pay for the home health services. You say that you changed some of the data on your 
claim, but it was still denied. 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 28, 2022. The NOA was not received by the Plan until May 27, 
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 January 28, 2022, to February 26, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Select MDx testing (0339U) provided on January 19, 2023. 
 
You asked the Plan to pay for the Select MDx testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that this testing was not medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the Select MDx testing by a contract provider. The file does not show that the 
plan provided notice that the Select MDx testing would not be covered. Under Medicare rules, this means the 
Select MDx testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
Select MDx testing (0339U) provided on January 19, 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.