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

 
We decided that the Plan has to pay for hospital discharge management (99238) provided on June 5, 2021. 
 
You asked the Plan to pay for hospital discharge management. You say that the provided records support the 
service billed. The Plan denied your request. The Plan says that the code at issue is inclusive to another billed 
code. 
 
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 99238 is "Hospital discharge day management; 30 minutes 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 hospital discharge management. Our reviewer says that the 
billed code meets criteria for reimbursement. Our reviewer found that the provided documentation describes 
critical care services performed: the enrollee was intubated and then expired. A hospital discharge was 
performed. The documentation does not support that the enrollee was intubated during the hospital discharge 
service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hospital discharge management have been met. Therefore, we decided that the 
Plan has to pay for hospital discharge management (99238) provided on June 5, 2021.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from July 9, 2020, to 
July 16, 2020, billed with DRG 981. 
 
You asked the Plan to pay for inpatient services as billed with DRG 981. You say that these services were 
billed correctly, and this diagnosis is supported in the record The Plan denied your request. The Plan says DRG 981 is not supported as the secondary diagnosis of metabolic encephalopathy (G93.41) is not supported. The 
Plan says that DRG 983 is more appropriate in this case. 
 
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. DRG 981 requires a secondary diagnosis of metabolic 
encephalopathy (G93.41). 
 
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 inpatient services billed with DRG 981. Our 
reviewer says that DRG 981 is not supported in this case. Our physician reviewer found that the enrollee 
presented on July 9, 2020, with generalized weakness and underwent gynecologic surgery. The enrollee was 
discharged the same day in a stable condition but returned to the emergency department two days later with 
complaints of fatigue and abdominal pain. The emergency department provider noted that the enrollee was 
awake and alert, and the physical exam reflects neurologic at baseline according to the family member. While 
the enrollees presentation warranted consideration of metabolic encephalopathy as a diagnosis, there was no 
evidence of a change in mental status which is beyond baseline and supported by neurological examination 
findings documented by licensed provider corroboration. The review has determined that the medical records 
did not support the billing of secondary diagnosis metabolic encephalopathy (G93.41). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services billed with DRG 981 have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient hospital services provided from July 9, 2020, to July 
16, 2020, billed with DRG 981.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantion of neurostimulator electrode 
array. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are other options that have yet to be tried. 
 
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 the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is not being requested as a last resort. Detailed documentation is not evident regarding trial and 
failure of recent, reasonable, and comprehensive less invasive conservative care measures. Other treatment 
modalities have not been exhausted or contraindicated. Detailed documentation is not evident regarding failure 
of any physical therapy and/or injections for the treatment of her low back pain. There is limited published, 
large-scale, long-term peer-reviewed literature that shows spinal cord stimulation to be an effective and/or safe 
treatment for the noted pathology without failure of conservative treatments as a last resort treatment. There has 
been a physical and psychological evaluation. However, the psychological evaluation suggested a face-to-face 
consultation to rule out the presence of depression that needs to be treated is likely the most prudent course. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous implantion of neurostimulator electrode array.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prosthetic leg with advanced foot, ankle feature and 
other parts (L5968). 
 You asked the Plan to pre-approve the prosthetic leg with advanced foo. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item 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 the prosthetic leg with advanced foo. 
Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the medical documentation doesn't indicate that the member is a K3 level 
ambulator. 
 
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 prosthetic leg with advanced foo have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the prosthetic leg with advanced foot, ankle feature and other parts 
(L5968).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 0242U) provided on April 
10, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 0242U 
remains no supported. The Place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in outpatient hospital, POS 22. Furthermore, the patient resides in Wisconsin 
and the billing laboratory is located in Illinois. It is noted multiple attempts were made to obtain additional 
information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory 
service (CPT code 0242U) provided on April 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (S9338) provided from June 17, 
2021, through June 18, 2021. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this code is not eligible for payment 
according to Medicare rules. 
 
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 S9338 is home infusion therapy, immunotherapy, 
administrative services, professional pharmacy services, care coordination, and all necessary supplies and 
equipment (drugs and nursing visits coded separately), per diem. 
 
We looked at the file and Medicare rules. In this case, CPT code S9338 has a Status Code of I under the 
Physician Fee Schedule. This Status Code indicates that this code is not valid for Medicare purposes. Based on 
this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9338) provided from 
June 17, 2021, through June 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice room and board services provided from  
May 1, 2021, through May 4, 2021. 
 
 
 
 
 You asked the Plan to pay for hospice room and board services. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospice room and board services provided from May 1, 2021, 
through May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 81479). 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met CPT code 81479 (1 Unit) 
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on June 02, 2021, and received by the lab on June 03, 2021. Of note, the patient resides 
in New York and the billing laboratory is located in Illinois therefore the billed code cannot be verified. It is 
noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (CPT code 81479).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on January 25, 2021. 
 
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 procedure code 49010 is not separately payable. 
 
  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 49010 (exploration behind abdomen) and 38115 (repair of 
ruptured spleen). Code 49010 is a column II code with a modifier indicator of 1 when billed with column I 
code 38115. Code 49010 was not billed with an appropriate modifier to allow for separate payment. Therefore, 
we decided that the Plan does not have to pay for the surgical services rendered on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan (93971) provided on October 30, 2021. 
  You asked the Plan to pay for the duplex scan (93971). The Plan denied your request. The Plan says an 
appropriate modifier was not billed with this code edit. 
 
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 93971 
is a column II code to column I code 93970. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the duplex scan (93971) provided on October 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ConfirmMDx testing provided on July 23, 2021. 
 
You asked the Plan to pre-approve the ConfirmMDx testing. You say that this testing is covered by Medicare 
for the patient's condition. The Plan denied your request. The Plan says there was no PSA testing after prior 
biopsy to show that repeat biopsy was considered. 
 
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx testing is covered for patients who have 
undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for repeat 
biopsy due to persistent or elevated cancer-risk factors.  
 
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 ConfirmMDx testing. Our reviewer 
says that the documentation does not support the use of this testing at this time. Our physician reviewer found 
the enrollee is a male with elevated prostate-specific antigen (PSA) levels at 4.7ng/mL with a lesion found on 
imaging. He underwent biopsy on July 23, 2021, which was negative, and this sample was immediately sent for 
ConfirmMDx testing. There was no interval PSA testing done after the initial biopsy to show persistent or elevated cancer risk. 
 
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 ConfirmMDx testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the ConfirmMDx testing provided on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of 3D rendering of imaging and the 
ultrasound guidance for needle placement provided on June 25, 2021, billed with codes 76377-26 and 76942-
26-XU, respectively. You asked the Plan to pay for the services as billed. You say that these services are billed correctly and should 
be paid. The Plan denied your request. The Plan says the billed services are 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. 
 
We asked our coding 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 as billed. Our reviewer says that 
the billed services are not supported by the records. Our coding reviewer found the radiology report does not 
include enough information to confirm the description criteria have been met for this procedure. The record 
does not include documentation to support the 3D post-processing images were reconstructed on an 
independent workstation with concurrent physician supervision. Therefore, this procedure cannot be 
confirmed.   
 
76942 is a Column 2 code in relation to other codes billed on the claim. There is not sufficient documentation 
to support the use of modifier -XU to bypass the edit since there is nothing to indicate this is a non-overlapping 
service. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the interpretation of 3D rendering of imaging and the ultrasound guidance for needle 
placement provided on June 25, 2021, billed with codes 76377-26 and 76942-26-XU, respectively.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy provided on September 2, 2021. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says that provider 
must attempt to consult the attending or primary care physician about the services furnished. 
 
The Plan must follow Medicare rules. The rules say that when services are rendered by a Clinical Psychologist 
and the patient consents, you must attempt to consult their attending or primary care physician about the 
provided services. This does not apply if the physician referred the patient to the Clinical Psychologist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have been met. Specifically, the submitted claim includes a referring provider. 
Documentation of a consultation is not required when there is a referring physician. Therefore, we decided that 
the Plan has to pay for psychotherapy provided on September 2, 2021.  
 
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 lab testing services provided on June 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that you were compliant with the regulations for 
billing. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The claim billed a place of service as 81, an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
medical records do not indicate the enrollees sample was obtained at the independent laboratory. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on June 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 11044, 11047, and 97608 
provided on October 15, 2021. 
 You asked the Plan to pay for the medical services. You say that the documentation supports the services as 
they were billed. The Plan denied your request. The Plan says the medical records do not support payment for 
the coded services. 
 
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 definitions of code 11044, 11047, and 97608 are the following: 
 
11044 -  Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if 
performed); first 20 sq cm or less  
 
11047 -  Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if 
performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary 
procedure)  
 
97608 -  Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-
durable medical equipment including provision of exudate management collection system, topical 
application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area 
greater than 50 square centimeters 
 
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 medical services. Our reviewer says that the 
documentation does not support the services billed. Our reviewer found the documentation does not support 
CPT 11044. Per the operative report the depth of debridement was down to the sternum (bone). Per CPT 
Assistant, "Depth is defined progressively from the skin level down through to the bone." Documentation does 
not state the bone was actually debrided. Therefore, CPT 11044 will not be reimbursed. Furthermore, we have 
confirmed that code 11047 is an add-on code. As the primary procedure CPT 11044 for the date of service was 
denied, payment for the add-on code will not be allowed. Based on the claim submitted, Medicare billing 
criteria have not been met. The review has determined that the documentation did not support that codes 11044 
and 11047 (add on code) were billed correctly based on the services rendered. The documentation did not 
support that code 97608 was billed correctly based on the services rendered. 
 
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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services coded 11044, 11047, and 97608 provided on October 15, 2021.