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

 
We decided that the Plan does not have to pay for procedure codes 75710, 75625, and 37197 billed for date of 
service March 24, 2022. 
 
You asked the Plan to pay for procedure codes 75710, 75625, and 37197. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for code 75710 is bundled into payment for 
code 37225. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 75710 
is a column II code to column I code 37225. While code 75710 was billed with modifier -59, the medical 
records provided do not show that the service billed with the -59 modifier is a distinct procedural service.  
 
We find that CPT code 75625 is not supported in the medical record. Specifically, the operative report did not 
include documentation of radiological supervision and interpretation of an abdominal aortography by 
serialography; therefore, code 75625 cannot be verified. 
 
We find that CPT code 37197 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a percutaneous transcatheter retrieval of an intravascular foreign body (fractured 
venous or arterial catheter), including radiological supervision and interpretation, and imaging guidance 
(ultrasound or fluoroscopy), when performed; therefore, code 37197 cannot be verified. 
 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 75710, 75625, and 37197 billed for date of service March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
October 24, 2022. 
 
You asked the Plan to pay for the CGM supplies. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation submitted did not include a proof of delivery or a 
delivery ticket. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the documentation submitted did not include a valid proof of delivery or a delivery ticket to indicate 
the specific supplies rendered. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor (CGM) supplies provided on October 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 19, 2022, to 
September 2, 2022. 
 
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied 
your request. The Plan says this was not billed with the required Federal Information Processing Standards 
(FIPS). 
 
The Plan must follow Medicare rules. Medicare rules say that home health payments must be based upon the 
site at which the beneficiary is served. Where required by law or regulation, report the Federal Information 
Processing Standards (FIPS) State and County Code of the place of residence where the home health service is 
delivered under value code 85. 
 
We looked at the file and Medicare rules. The services at issue were not billed with a FIPS code under value code 85. 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 pay for home health services provided on 
August 19, 2022, to September 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional miles for routine transportation. You say that you need rides to 
your doctor's office. The Plan denied your request. The Plan says the requested trip exceeds the Plan's mileage 
limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.  
 
We looked at your request, the records in the case file, and the rules. The requested trip is greater than 50 miles 
of driving distance. Based on this information, we decided that the Plans rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional 
miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat facet joint injections. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat facet injections are covered when specific 
criteria 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that the enrollee has chronic low back 
pain and underwent right-sided diagnostic medial branch blocks (MBBs) on March 23, 2023. She reported at least 60 percent pain relief and at least 50 percent improvement in function for the first six to eight hours after 
the injection. The result did not achieve 80 percent pain relief; therefore, the criteria are not met and the repeat 
injections are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services (procedure code 97597) rendered on 
September 21, 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 debridement size is only documented for the wound debridement of the third toe on the left 
foot, which supports CPT 11044 that was also 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 code 97597 is "Debridement (eg, high pressure waterjet 
with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, 
devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound 
assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) 
surface area; first 20 sq cm or less." 
 
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 medical records do not 
support the use of an additional procedure code of 97597, as this was included within the billed primary 
procedure code. 
 
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 debridement services (procedure code 97597) rendered on September 21, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided August 17, 2022, to August 
24, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that an admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was not considered medically stable on August 24, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided August 17, 2022, to August 24, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the MI profile provided on November 21, 2022. 
 
You asked the Plan to pay for the MI profile. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the claim for this testing is not approved by the Food and Drug Administration 
(FDA). 
 
 
 The Plan must follow Medicare rules. The rules say that diagnostic laboratory tests must undergo an 
application and technical assessment process through the Molecular Diagnostics (MolDX) contractor. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the testing rendered is 
covered. The testing is not FDA approved. Based on this information, we decided that Medicare rules for 
coverage of the MI profile have not been met. Therefore, we decided that the Plan does not have to pay for the 
MI profile provided on November 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on October 17, 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 87641) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
provider did not send in any lab report or lab results for this testing. The testing cannot be verified.. Therefore, 
we decided that the Plan does not have to pay for laboratory services rendered on October 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office or other outpatient visit provided from  
January 20, 2022, to April 28, 2022. 
 
You asked the Plan to pay for the office or other outpatient visit. The Plan denied your request. The Plan says 
the member's Plan excludes coverage for this out-of-network service. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for office or other outpatient visit provided from January 20, 2022, 
to April 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service September 1, 
2022. 
 You asked the Plan to pay for procedure code 86077. You say that you disagree with the Plan's denial. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two home health periods of care beginning on April 16, 
2021, billed with code 2CB11.  
You asked the Plan to pay for the home health periods of care. You say that this was billed correctly and should 
be paid. The Plan denied your request. The Plan says the incorrect first digit was used in the billing code. 
 
The Plan must follow Medicare rules. Medicare rules say that the first digit of a home health billing code can 
be reported as 2 on the first period of care, only if the enrollee was admitted from an inpatient facility.  
 
We looked at the file and Medicare rules. The Plan has indicated that the enrollees hospital stay was 
outpatient, meaning that the first digit of the payment code cannot be 2. Based on this information, we decided 
that Medicare rules for coverage of the home health periods of care have not been met. Therefore, we decided 
that the Plan does not have to pay for the two home health periods of care beginning on April 16, 2021, billed 
with code 2CB11.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from October 18, 2021, 
to October 22, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
submitted supporting documentation for reconsideration. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay clinical validation audit shows that the provider has reported inpatient 
hospital services with the incorrect DRG. 
 
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 DRG 871. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the enrollee presented with dehydration and a diagnosed urinary tract infection. He had leukocytosis and 
hypothermia at 95.8. He also had an initial lactic acid level of 4.8. He did not however have any SOFA criteria 
- hypotension, low platelets, persistent hypoxia, liver enzyme disorder, renal impairment or mental status 
change.  
 
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 rendered from October 18, 2021, to October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that you underwent SI joint fusion 
surgery on February 1, 2023. You presented on March 7, 2023 with complaints of severe left foot pain for the 
past two weeks. The foot pain is not associated with SI joint pain. There is no documentation of three 
diagnostic maneuvers to support the diagnosis of sacroiliitis. The SI joint injection is therefore not reasonable 
or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from April 17, 2022, to 
April 24, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
supporting documentation was submitted for reconsideration of the DRG adjustment. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay clinical validation audit shows that the 
provider has reported inpatient hospital services with the incorrect DRG. 
 
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.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found that the enrollee was acutely ill in setting of chronic illness. SOFA 
criteria, the international consensus on diagnosis of sepsis were not present. No persistent hypotension after 
simple volume resuscitation, mental status change is part of acute illness with dementia and was at a minor 
level without support for sepsis. The low platelet count occurred well after the acute phase had passe. The 
adjustment for sepsis was correct  
 
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 rendered from April 17, 2022, to April 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services billed for date of service 
September 29, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you believe the payment is too low 
for these services. The Plan denied your request. The Plan says you billed a code that is not allowed under 
OPPS, so the entire claim cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that on Outpatient Prospective Payment System 
(OPPS) claims, codes with a status indicator of E1 are not paid under OPPS or any other Medicare payment 
system. These codes are not paid under OPPS and an alternate code may be available. 
 
The Outpatient Prospective Payment System (OPPS) Addendum B shows that one of the billed codes on this 
claim (S5000) has a status indicator of 'E1'. OPPS claims cannot be paid if individual line items are incorrect. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not 
have to pay for outpatient hospital services billed for date of service September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on June 
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 Current Procedural Terminology (CPT) 99223 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. 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
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 history and physical are 
abbreviated. The exam is not detailed - there is no comment on the pupils, no exam of the middle ear, no 
comment on apical beat, no vascular in an enrollee undergoing catheterization, and certainly no complexity for 
an enrollee reporting for an elective catheterization procedure. 
 
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 initial hospital care (procedure code 99223) rendered on June 9, 2022.