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

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) panel (87481, 87500, 87640, 
87652, 87798, 87799 and 87900) billed for date of service September 12, 2023. 
 
You asked the Plan to pay for the UTI panel. You say that this testing was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says this test should be billed with a single panel code 
according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the urinary tract infection (UTI) panel (87481, 87500, 87640, 87652, 87798, 
87799 and 87900) billed for date of service September 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87801, 87500) provided on February 13, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not payable. 
 
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 87801 is "Infectious agent detection by nucleic acid 
(DNA or RNA), multiple organisms; amplified probe(s) technique". 
 
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 use of code 87801 is 
not supported by the records provided. Our reviewer found that codes that test for multiple infectious agents are 
reported with one unit of service if one procedure, one methodology, or one test kit is used to perform the test. 
In this case, the services were incorrectly reported, and 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 code 87801 have not been met. 
 
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 87500 is 1. The MAI value for this code is 3. You billed 2 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 87500 have not been met. Therefore, we decided that the 
Plan does not have to pay for the services (87801, 87500) provided on February 13, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing visits (G0299 x9). 
 You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found  the Health 
Plans denial should be upheld. The enrollee does not have documented skilled nursing needs. As such, home 
health skilled nursing services are not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing visits (G0299 x9).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing billed for date of service July 27, 2023. 
 
You asked the Plan to pay for the lab testing. You say that the clinical utility of the testing is supported. The 
Plan denied your request. The Plan says that the test is not covered. 
 
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 DEX Diagnostics Exchange shows that the provided 
post-surgery Guardant Reveal test is a covered test. The records show that this test at issue was provided after 
the enrollees surgical procedure on January 9, 2023. Based on this information, we decided that Medicare 
rules for coverage of the lab testing have been met. Therefore, we decided that the Plan has to pay for the lab 
testing billed for date of service July 27, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided September 
6, 2023. 
 You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 service. Our reviewer found that the emergency 
department (ED) visit does not meet criteria for the billing of CPT 99285. The history and physical were 
appropriate, but the medical decision making was not 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency department visit (99285) provided September 6, 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 multiple 
power options, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and additional items and accessories (codes E0955, E0957, E1007, E1012, E1028, E2300, E2311, E2313, E2363 
x2, E2377, E2605, E2620, and K0108). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that  tilt and recline 
together would be an asset to the enrollee. The Plan denied your request. The Plan says the enrollee does not 
have medical need for multiple power options included with K0861 group 3 power wheelchair. The Plan also 
says the electronic connection, expandable controller and expandable controller harness cannot be covered as it 
is not medically necessary to control the three requested power options through the joystick (drive interface). 
 
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 the durable medical equipment (DME). 
Our physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 standard power wheelchair with multiple power 
options, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and additional 
items and accessories (codes E0955, E0957, E1007, E1012, E1028, E2300, E2311, E2313, E2363 x2, E2377, 
E2605, E2620, and K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653, and 87798 provided 
on July 31, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87653, and 87798. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 87481, 87640, 87653, and 87798 provided on July 31, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that admission is medically necessary for you. The Plan 
denied your request. The Plan says you do not have any additional needs requiring a daily skilled level of care, 
your current needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service 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 an Intracept procedure. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no magnetic resonance imaging (MRI) scan evident in the case record to show only 
Modic changes without facet degenerative joint disorder (DJD) or stenosis. The cause of the enrollee's pain is 
not clear.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services rendered on February 9, 2023. 
 You asked the Plan to pay for the services. You say that the services were medically necessary for the enrollee 
to go to a facility to treat their medical needs. The Plan denied your request. The Plan says the services were 
not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that the 
enrollee presented to a hospital with abdominal pain. The enrollee was found to have an adnexal mass and 
admitted for additional evaluation. While subsequent evaluation by a gynecologic oncologist was reasonable, it 
does not appear that this evaluation was emergently needed. Transport by an air ambulance did not offer any 
benefit to the enrollees care. The enrollee could have been safely transported by other means (ground 
ambulance, stretcher van, private car) without an expected decline in her condition. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for air ambulance services rendered on February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 25, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services should be covered. 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 an office visit provided 
on August 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services described by code 01402 performed 
on date of service July 25, 2023. 
 
You asked the Plan to pay for 01402. You say that 01402 should be paid as billed because the diagnosis codes 
assigned are valid and reimbursable. The Plan denied your request. The Plan says 01402 is denied because it is 
not appropriate to bill a left and right sided diagnosis code when a bilateral code is available. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must comply with the Official 
International Classification of Disease, 10th Edition, Clinical Modification (ICD-10-CM) Coding Guidelines. The rules also say when available, providers should use bilateral codes to describe bilateral conditions. If no 
bilateral code exists, then providers should assign separate codes for the left and right side. 
 
We looked at the file and Medicare rules. In this case, we confirmed that 01402 was billed with diagnosis codes 
M17.11 (unilateral primary osteoarthritis, right knee) and M17.12 (unilateral primary osteoarthritis, left knee). 
We confirmed there is a bilateral diagnosis code, M17.0 (bilateral primary osteoarthritis of knee), which should 
have been reported instead. Based on this information, we decided that Medicare rules for coverage of 01402 
have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services 
described by code 01402 performed on date of service July 25, 2023.
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 the enrollee is willing and able to participate in the 
required therapy. The Plan denied your request. The Plan says the services the enrollee needs can be provided 
safely in other settings, for example, a skilled nursing facility (SNF), home with home health services or home 
with outpatient therapy.  
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable and there are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 32551-59 rendered on September 5, 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 that Current Procedural Terminology (CPT) code 32551-59 (1 Units) remains not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that the 
medical record includes a progress note for post operative coronary artery bypass graft (CABG), and a 
procedure report for a chest tube insertion. The records do not show that these procedures were done at the 
same time.  Two procedures were billed - one was for the heart, and one was for the lungs. As the procedure 
report for the heart procedure was not submitted, the plan's denial that these services were related cannot be 
verified. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 32551-59 rendered on September 5, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 18, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services did not meet the criteria for approval. 
 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 office visit provided on January 18, 2023, by 
an out-of-network (OON) provider.