Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 75625 and 75710. We decided that the Plan does not have to pay for 
37232 and 37253.  
 
You asked the Plan to pay for revascularization, intravascular ultrasound, aortography, and angiography 
provided to the enrollee on October 3, 2022.. You say that this should be paid for. The Plan says that the 
records do not support the services. 
 
We decided that the Plan has to pay for 75625 and 75710.  
 
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 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 for CPT 75625 and CPT 75710. Our reviewer says that 
the records support that these codes were satisfactorily documented as performed. 
 
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 
75625 and 75710.  
 
We also decided that the Plan does not have to pay for 37232 and 37253. 
 
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 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 for CPT 37232 and 37253. Our reviewer says that the 
diagnostic angiography is not considered a component of lower extremity intervention and is separately billable 
unless there was a recent diagnostic angiogram. In this case, there is no evidence of a recent angiogram and no 
claim of such by the health plan. Pedal arteries are considered extensions of the corresponding tibial artery.  As 
the pedal arch was treated along the same axis as the peroneal artery it is considered a component of the 
peroneal artery, and the treatment of this has been previously approved.  Therefore, the documentation is 
insufficient to justify the add-on code of 37232, coding for angioplasty of an additional tibial artery. There is 
inadequate documentation of the intravascular ultrasound (IVUS) interpretation to justify the use of CPT 
37253. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37232 and 37253 have not been met. Therefore, we decided that the Plan does 
not have to pay for 37232 and 37253. 
 
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 definitive urine drug testing (22+ drug classes) provided to 
the enrollee on August 22, 2022. 
 
You asked the Plan to pay for the testing. You say that this is a Medicare-covered service ordered by a treating 
physician. The Plan denied your request. The Plan says the records do not show screening test results which are 
positive or inconsistent with prescription medications, dosing schedules, or history and expected results. 
 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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the reviewed documentation indicates that the diagnosis at the time was medication management of 
long term (current) drug therapy. The medical record sent by the provider showed a definitive UDT panel for 
multiple drug classes was performed but did not show screening test results which were positive or inconsistent 
with prescription medications, dosing schedules, or history and expected results. The review has determined 
that the enrollee was not indicated for testing for 22+ drug classes. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for definitive urine drug testing (22+ drug classes) provided to the enrollee on August 22, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the services (76641) provided on October 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the MUE value 
has been exceeded. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that code 76641 has an MUE of 1, however, a CPT code search 
reveals that code 76641 has an MUE value of 2. Additionally, Medicare rules say that a bilateral diagnostic 
procedure may be reported with 1 unit of service with modifier RT on 1 claim line plus 1 unit of service 
and modifier LT on a second claim line, as was done in this case. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (76641) provided 
on October 14, 2022.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (procedure codes 97110, 97112, 97116, 
97140) provided to the enrollee from February 4, 2022, to February 9, 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 the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 97110: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and 
endurance, range of motion and flexibility 
 
CPT 97112: 
 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities 
 
CPT 97116: 
 
Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) 
 
CPT 97140: 
 
Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or 
more regions, each 15 minutes 
 
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 home services were provided and 
should be reported as such, not as services performed in the office setting. There is a more appropriate code to 
report in this instance. 
 
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 therapy services (procedure codes 97110, 97112, 97116, 97140) provided to the enrollee from 
February 4, 2022, to February 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services (Q9967, 71260, G1004 and 
G0463) provided on August 25, 2022. 
 
You asked the Plan to pay for outpatient services. You say that these services are supported in the medical 
records. The Plan denied your request. The Plan says there are one or more OCE edit errors which have caused 
this claim to deny. 
 
The Plan must follow Medicare rules. Medicare rules say that code G0463 has a Status Indicator of V, which 
means that this code is an Evaluation and Management (E&M) code used to report a medical visit that takes 
place on the same date that a procedure with status indicator S or T is performed, but that is significant and 
separately identifiable from the procedure. The rules say that when and E&M code is on the same day as a type 
T or S procedure does not have a modifier of 25, then edit 21 applies and the claim is returned to the 
provider for correction. 
 
The rules also say that services identified as information only service(s) are non-covered and will not be 
paid.  
 
We reviewed the I/OCE Specifications file for this date of service. OCE edit 21 is invoked when One or more 
type T or S procedures occur on the same day as a line item containing an E&M code, without modifier 25. 
G0463 is an E&M code which, in this case, was billed with 71260, which has a status indicator of S. Modifier 
25 was not billed with this service. Therefore, edit 21 applies and this claim is rejected to be returned to the 
provider for correction. 
 
In addition, code G1004 is an information only code and is not eligible for Medicare payment. Based on this 
information, we decided that Medicare rules for coverage of outpatient services have not been met. Therefore, 
we decided that the Plan does not have to pay for outpatient hospital services (Q9967, 71260, G1004 and 
G0463) provided on August 25, 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 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 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 you 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on June 9, 2022. 
 
You asked the Plan to pay for the anesthesia services. 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 anesthesia services have not been met. Specifically, this claim was billed with an outpatient 
POS code. The records do not support that the enrollee was an outpatient when the services were provided. 
Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on June 9, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Cogenex. 
 
You asked the Plan to pre-approve Cogenex. You say that the services are necessary. The Plan denied your 
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 Cogenex. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee needs the type of treatment offered by the Cogenex membrane. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Cogenex have been met. Therefore, we decided that the Plan has to pre-approve 
Cogenex.  
 
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 pre-approve six (6) office visits with a nephrologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you had a kidney transplant and need follow-up 
care but there are no providers in network. The Plan denied your request. The Plan says there are in-network 
providers available in the area. Transplantation nephrologists typically care for the patient in the first 6 months 
post-transplantation and general nephrologists and internists often care for kidney transplant recipients after 
this period. In this case, the transplant follow-up has been uncomplicated and there is no reason that you cannot 
follow-up with in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
six (6) office visits with a nephrologist to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. 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 follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients who meet specific criteria. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the magnetic resonance imaging (MRI) 
shows bone retropulsion which is a contraindication to kyphoplasty. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99239) provided on July 5, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99239 is "Hospital discharge day management; more than 
30 minutes". 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that 
more than 30 minutes of hospital discharge day management services were provided on the date of service in 
question. 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 the services (99239) provided on July 5, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 30, 2021, to 
August 4, 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 
diagnosis was billed appropriately, so this claim was underpaid. The Plan denied your request. The Plan says 
the diagnosis of toxic encephalopathy (G92) is not supported in the medical record. The removal of this 
diagnosis resulted in a lower DRG being paid. 
 
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 the diagnosis of toxic encephalopathy (G92). 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 diagnosis of toxic encephalopathy (G92) is not supported in the 
medical record. Our physician reviewer found the circumstances of inpatient admission always govern the 
selection of principal diagnosis. The principal diagnosis is defined as the condition established after study to be 
chiefly responsible for occasioning the admission of the patient to the hospital for care.  The definition for 
other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring: clinical 
evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased 
nursing care and/or monitoring. In this case, the documentation does not consistently and completely support 
the assigned principal diagnosis code with DRG. The replacement of DRG is upheld as it is supported by the 
medical documentation.  
 
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 30, 2021, to August 4, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extra heavy duty wheelchair (K0007). 
 
You asked the Plan to pre-approve an wheelchair. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for the requested wheelchair. 
 
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. An extra heavy duty wheelchair (K0007) is covered if the beneficiary 
weighs more than 300 pounds. The records indicates that the enrollee weighs 248 pounds. Based on this 
information, we decided that Medicare rules for coverage of an wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an extra heavy duty wheelchair (K0007).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance applied to an office visit provided on June 14, 2022. 
 
You asked the Plan to waive the coinsurance applied to the office visit. You say that you are disputing the bill 
you received because your doctor's office was billing your old insurance company. The Plan denied your 
request. The Plan says that the cost sharing will be applied according to the Plan contract. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees do not have to pay a coinsurance, copayment or deductible for 
Medicare-covered doctor's office visits. 
 
The Plan processed your claim for an out-of-network office visit provided on June 14, 2022, with a 20% 
coinsurance. Based on the Plan contract, however, you cannot be asked to pay a cost-sharing for an office visit. 
Therefore, we decided that the Plan has to waive the coinsurance applied to an office visit provided on June 14, 
2022.  
 
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.