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

 
We decided that the Plan does not have to pay for the emergency room evaluation and management (EM) 
services provided on December 17, 2022, billed with code 99285. 
 
You asked the Plan to pay for the EM services as billed. You say that this should be reimbursed as billed.  The 
Plan denied your request. The Plan says the code reported 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 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 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 EM services as billed. Our reviewer says 
that the EM services are not supported as billed.  Our reviewer found a comprehensive history requires a chief 
complaint, an extended history of present illness, a review of all additional body systems and a complete past, 
family and social history. A comprehensive examination requires a general multisystem examination or a 
complete examination of a single organ system and medical decision making of high complexity requires 2 out 
of 3 of an extensive number of diagnoses or management options, an extensive amount and complexity of data 
reviewed and high risk of complication.  
 
Provided records in this case document a chief complaint, an extended history of present illness, a review of all 
additional body systems and a complete past, family and social history, as well as a general multisystem 
examination. However, the records do not document an extensive number of diagnoses or management options, 
an extensive amount and complexity of data reviewed and high risk of complication. As such, the note does not 
support high complexity decision making.  
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the emergency room evaluation and management (EM) services provided on 
December 17, 2022, billed with code 99285.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20937, 20939, 63056 and 63057 billed for 
date of service December 8, 2022. 
 
You asked the Plan to pay for procedure codes 20937, 20939, 63056 and 63057. You say that the services at 
issue have been billed correctly. The Plan denied your request. The Plan says the provided 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. 
 
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 20937, 20939, 63056 and 63057. Our 
reviewer says that procedure codes 20937, 20939, 63056 and 63057 do not meet criteria for payment. Our 
reviewer found that the medical records provided do not include sufficient documentation to verify the procedures at issue. 
 
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 20937, 20939, 63056 and 63057 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20937, 20939, 63056 and 63057 billed for 
date of service December 8, 2022.
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 requires hands-on assistance to transfer, 
ambulate, and perform activities of daily living safely. You say the enrollee resides in a boarding home that 
requires independence. You say the enrollee is a registered sex offender and hospital staff have been unable to 
locate a SNF willing to accept him. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility, home 
health care, or outpatient services. 
 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 based on the documentation provided, the enrollee does not require the intensity of 
services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollees care needs can be met 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria has not been met, as you are dependent with daily home activities, and can 
ambulate without support in the apartment. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found that the enrollee is 
able to manage MRADLs in the apartment without an assistive device. A powered device 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 the scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Know Error DNA Specimen Provenance Assay (DSPA) 
(81266, 81265) provided on July 6, 2022. 
 
You asked the Plan to pay for the DSPA testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this test should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the DSPA testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Know Error DNA Specimen Provenance 
Assay (DSPA) (81266, 81265) provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on May 31, 2022. 
 
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 Current Procedural Terminology (CPT) code 99152 remains not supported. 
 
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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 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 no separate anesthesia record 
submitted for review in the medical records. This charge is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for moderate sedation services (procedure code 99152) rendered on May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service November 
28, 2022. 
 
You asked the Plan to pay for the billed services. You say that the data points determine the level of coding.  
The Plan denied your request. The Plan says the billed code remains not supported.  
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity.  
 
 We find that CPT code 99223 is not supported in the medical record. Specifically, the records provided do not 
show that a comprehensive history or examination was provided. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99223 billed for date of service November 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 76942 billed for date of service June 30, 2022. 
 
You asked the Plan to pay for code 76942. You say that this code was billed correctly and should be paid. The 
Plan denied your request. The Plan says this code is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that codes performed in an outpatient hospital or 
ambulatory surgical center are assigned a status indicator on Medicare's Addendum B. Codes with status 
indicator N are considered packaged services.  Payment for these codes is packaged into payment for other 
services.  Therefore, there is no separate payment for these codes. 
 
The code in dispute in this case (76942) has a status indicator of N on Addendum B. This means that no 
separate payment is made for this code. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 76942 have not been met. Therefore, we decided that the Plan does not have to pay for code 
76942 billed for date of service June 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 14, 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 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 
December 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 17, 2022, to 
November 12, 2022. 
 You asked the Plan to pay for the home health services. You say that you timely filed this NOA and provided 
evidence of your submission of the NOA to Original Medicare. The Plan denied your request. The Plan says 
the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 17, 2022. The NOA was not received by the Plan until December 
6, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Please note that submitting the NOA to Original Medicare is not sufficient- the NOA must 
be timely filed with the Plan. Therefore, we decided that the Plan does not have to pay for home health services 
provided from October 17, 2022, to November 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genicular nerve branch injection rendered on December 2, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was experimental and investigational. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer found that this is considered an experimental and investigational therapy, and is the subject of ongoing clinical 
trials. Therefore, the 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a genicular nerve branch injection rendered on December 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 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 screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on August 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Kardia Device/Kardia Mobile. 
 
You asked the Plan to pay for a Kardia Device/Kardia Mobile. You say that this device is recommended to for 
the enrollee's irregularity. The Plan denied your request. The Plan says this device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that FDA-approved devices are covered when criteria 
are met. 
 
We looked at the file and Medicare rules. In this case the device at issue is not FDA-approved. Based on this 
information, we decided that Medicare rules for coverage of a Kardia Device/Kardia Mobile have not been 
met. Therefore, we decided that the Plan does not have to pay for a Kardia Device/Kardia Mobile.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 32663, 32668, 36274 rendered on May 10, 
2022. 
 
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 these codes are not appropriate for 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 the denied codes is: 
 
CPT 32663: 
 
Thoracoscopy, surgical; with lobectomy (single lobe) 
 
CPT 32668: 
 
Thoracoscopy, surgical; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure) 
 
CPT 32674: 
 
Thoracoscopy, surgical; with mediastinal and regional lymphadenectomy (List separately in addition to code 
for primary procedure) 
 
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 CPT 
32668, as there was no documentation of a wedge resection. The records also do not support CPT 32663, as the 
procedure described did not indicate that a lobectomy was performed. Finally, the medical records do not 
support the procedure code CPT 32674 as this is an add on code in tandem with CPT 32663 which is not 
supported. There is a more appropriate code to capture the biopsy part of this procedure that can be coded. 
 
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 codes 32663, 32668, 36274 rendered on May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the DecisionDx-SCC (0315U) provided November 29, 
2022. 
 
You asked the Plan to pay for  the laboratory service. You say that your claim for the DecisionDx-SCC test was 
denied in error and you are requesting it be reprocessed and paid. The Plan denied your request. The Plan says 
this test is considered experimental and investigational and is not covered by Medicare. 
 
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. Per DEX Diagnostic Exchange, DecisionDx-SCC is not covered by Medicare. Use of molecular tests sch as DecisionDx-SCC are not considered standard of care for determining 
treatment of squamous cell carcinoma. Its use is not supported by NCCN guidelines or the medical literature. In 
addition, per Plan policy Proprietary Laboratory Analyses (PLA) Codes, 0315U is listed as a PLA noncovered 
due to experimental and investigational status. 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 DecisionDx-SCC (0315U) provided November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20936 and 20930 billed for date of service 
January 10, 2023. 
 
You asked the Plan to pay for procedure codes 20936 and 20930. You say that you disagree with the denial. 
The Plan denied your request. The Plan says procedure codes 20936 and 20930 are 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 codes 20936 and 20930 has a status indicator of B on the Physician Fee Schedule. This 
means that procedure codes 20936 and 20930 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20936 and 20930 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20936 and 20930 billed for date of service 
January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360 and 88381 billed for date of service 
June 16, 2022. 
 You asked the Plan to pay for procedure code(s) 88360 and 88381. The Plan denied your request. The Plan 
says this code is included in the facility payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360 and 88381. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360 and 
88381. Based on this information, we decided that Medicare rules for coverage of procedure code 88360 and 
88381 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88360 and 88381 billed for date of service June 16, 2022.