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

 
We decided that the Plan does not have to pay for lab services billed with code 87426 for date of service 
December 29, 2021. 
 
You asked the Plan to pay for code 87426. You say that this was a COVID-19 test that should be paid in full. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on September 20, 2022. Comparison of the two claims shows these are exact 
duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for code 87426 have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services billed with code 87426 for date of 
service December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on June 7, 2023. 
 
You asked the Plan to pay for the lab panel. The Plan denied your request. The Plan says there is a more 
appropriate code for the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab panel provided on June 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve a seat lift mechanism. 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 a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 pre-approve a seat lift mechanism. Our reviewer 
says that the services are not medically necessary Our physician reviewer found there is insufficient documentation indicating the enrollees level of independence with transfers and if the requested power seat lift 
would allow her to be independent with transfers. 
 
Therefore, the requested power seat lift chair 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 a seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service April 17, 2023. 
 You asked the Plan to pay for the lab services. You say that this testing was medically necessary and covered 
by Medicare. The Plan denied your request. The Plan says you did not bill the correct date of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, lab services should be billed with the 
date of service of when the specimen was collected. There is an exception for molecular pathology testing 
(such as the lab services at issue in this appeal).  However, in order for the actual testing date to be considered 
the date of service in this circumstance, certain criteria must be met. In this case, there is no evidence in the 
medical records you supplied that the patient was a hospital outpatient at the time the specimen was collected. 
There are no records at all showing a connection to an outpatient hospital service.  This is a requirement in 
order for the date of the testing to be used as the date of service for molecular pathology services.  Because that 
is not the case, the date of the specimen collection should have been used as the date of service instead.  That 
date was April 6, 2023. 
 
In this case, you billed these services with date of service April 17, 2023. The medical records indicate that the 
specimen was taken on April 6, 2023. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services billed for date of service April 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0955, E1002, E1028, E2361, and E2607). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the requested equipment is necessary for the enrollee to continue living safely at home with 
independence. The Plan denied your request. The Plan says the enrollee does not have medical need for power 
tilt option included with a K0856 group 3 power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with single power option (such as 
code K0856) is covered if the criteria listed in the Medicare rules section of this letter are met. Medicare rules 
also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
  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 a group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee requires a power wheelchair for mobility and 
accomplishing their daily activities. However, the clinical documentation is insufficient why a lower-level 
power wheelchair would not suffice for the enrollee's needs versus a group 3 power wheelchair. There is 
inadequate clinical documentation regarding why the enrollee requires power tilt and cannot perform pressure 
relief. Our reviewer found that the enrollee has no history of skin breakdown and can still ambulate short 
distances. The enrollee has no history of skin breakdown and does not have a diagnosis that would be 
consistent with impaired sensation in pressure bearing areas, such as with spinal cord injury.  Our physician 
reviewer also found that there is a lack of documentation supporting a group 3 power wheelchair base, which 
are typically indicated for patients with significant paralysis, such as with spinal cord injury or multiple 
sclerosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E0955, E1002, 
E1028, E2361, and E2607).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204-25 billed for date of service July 12, 
2023. 
 
You asked the Plan to pay for the billed services. You say that modifier -25 unbundles the code.  The Plan 
denied your request. The Plan says the code is not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that CPT code 99204-25 is not supported. Modifier 25 is used to 
identify evaluation and management services that are separately identifiable from minor surgery or endscopic 
procedures. The other codes billed on this date of service, 95886 and 95911, are not considered a minor surgery 
or endoscopic procedures. There are also no code edits for code 99204 with the other billed codes. The 
modifier is not billed correctly in this case. Code 992004 is not payable as billed in this case. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99204-25 billed for date of service July 12, 2023.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that this service is medically 
necessary. The Plan says that additional visits are not medically necessary. 
 
We decided that the Plan has to pre-approve 2 additional therapy visits.  
 
A review of the provided records show that 2 additional visits are reasonable to ensure a thorough review of an 
independent home exercise program. Therefore, we decided that the Plan has to pre-approve .  
 
We also decided that the Plan does not have to pre-approve 8 additional visits. 
 
Records show that beyond the initial 2 visits, the unique skills of a professional therapist are not required. 
Therefore, we decided that the Plan does not have to pre-approve 8 additional visits. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service June 6, 2023.  
 You asked the Plan to pay for procedure code 88341. You say that these services were reported correctly. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 15 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77387 billed for date of service April 3, 
2023. 
 
You asked the Plan to pay for procedure code 77387. You say that you disagree with the Plan's 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 77387 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77387 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77387 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77387 billed for date of service April 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on November 8, 2022. 
 
You asked the Plan to pay for the lab panel. The Plan denied your request. The Plan says this 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 pay for the lab panel. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is a 78-year-old male who presented with shortness of breath, congestion, rhinorrhea, and sore throat. A swab throat sample was taken. A lab wound panel and respiratory pathogen panel were 
ordered. However, the wound panel was not sufficiently supported as broad polymerase chain reaction (PCR) 
testing has not been shown to be superior to culture in this clinical situation or lead to improved outcomes. 
Therefore, this request is considered 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 lab panel have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab panel provided on November 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Urine PCR panel testing provided July 4, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that kindly review the attached documents and 
process this claim towards possible payment. The Plan denied your request. The Plan says the PCR testing is 
considered unproven and 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 looked at the file and Medicare rules. 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 service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Urine PCR panel testing provided July 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 3, 2023. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility visit provided on June 20, 2023, by an 
OON provider. 
 
You asked the Plan to pay for the nursing facility visit. You say that appealing  The Plan denied your request. 
The Plan says the services were provided out-of-network and were not approved in advance. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the nursing facility visit provided on June 20, 2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 31, 2023, billed with 
codes 87801-90 x3, 8779890, XU x12, 87481 -90, XU. 
 
You asked the Plan to pay for the genetic testing billed. 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. 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. 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 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on May 31, 2023, billed with codes 87801-90 x3, 8779890, XU x12, 87481 -90, XU.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiaflex (J0775). 
 
You asked the Plan to pre-approve Xiaflex. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this is not covered under Medicare Part B when the 
drug does not represent an expense to the physician 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Xiaflex (J0775).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary. The Plan denied your request. 
The Plan says IRF care is not reasonable or necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. The medical records do not support that you would meet criteria for 
admission to an acute inpatient rehabilitation facility. You can receive further services at a lower level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service May 30, 2023. 
 
You asked the Plan to pay for the billed services. You say that the testing is a covered benefit. The Plan denied 
your request. The Plan says that the unique identifier is registered to a different manufacturer. 
 
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. A review of the claim does show that the required unique identifier 
was reported. The DEX Z code is associated with a lab/manufacturer that is a subsidiary of the billing provider.  
Based on this information, we decided that Medicare rules for coverage of the billed services have been met. 
Therefore, we decided that the Plan has to pay for the lab testing billed for date of service May 30, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
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 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.