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

 
We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on June 25, 
2021. 
 
You asked the Plan to pay for the moderate sedation services (99152). The Plan denied your request. The Plan 
says procedure codes 93460 and 76937 have been overturned. The Plan also says that CPT code 99152 remains 
denied as the documentation did not indicate the presence of a trained observer. 
 
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 find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
a trained observer to assist in monitoring the patient's level of consciousness and physiological status as 
required. Based on this information, we decided that Medicare rules for coverage of the moderate sedation 
services (99152) have not been met. Therefore, we decided that the Plan does not have to pay for the moderate 
sedation services (99152) provided on June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (codes 82310, 82728, 83540, 83550, 83970, 
84100, and 87340) provided on October 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that you do not have a contract in place to include these 
labs in the dialysis rate, so these lab services should be paid. The Plan denied your request. The Plan says these 
services are not separately payable for an End Stage Renal Disease (ESRD) patient. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services furnished ESRD patients are 
included in the ESRD Prospective Payment System as Part B services and are not paid separately. If the lab 
services are furnished for reasons other than for the treatment of ESRD, the provider should bill separately 
using the AY modifier. 
 In this case, the patient is an ESRD patient.  You did not bill these lab services with an AY modifier to indicate 
that they were furnished for any reason other than ESRD treatment.  According to Medicare rules, these lab 
services are not separately payable as billed. Therefore, we decided that the Plan does not have to pay for lab 
services (codes 82310, 82728, 83540, 83550, 83970, 84100, and 87340) provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided to the enrollee on September 23, 
2021. 
 
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 description of this code indicated that the telehealth visit cannot be separately payable if 
related to the previous evaluation and management (E/M) visit that was within seven days. 
 
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 99441 is "Telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 5-10 minutes of medical discussion." 
 
We find that CPT code 99441 is not supported in the medical record. Specifically, it was not appropriate to 
report this procedure separately. An E/M service was billed two days prior. 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 telehealth services provided to the enrollee on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services coded as 81191, 81317, 81321, 81295, 
81298, 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301 and 81311 provided June 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the billed service 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 CPT code. 
 
In this case, we find that CPT codes 81191, 81317, 81321, 81295, 81298, 81206, 81210, 81235, 81272, 81275, 
81276, 81292, 81301 and 81311 are not supported in the medical record. Specifically, the submitted claim form indicates the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the 
specimen was obtained. 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 Off 
Campus-Outpatient Hospital, POS 19. Also, the laboratory results submitted indicate the specimen was 
collected on 05/20/2021 and received by the lab on 05/25/2021. The Plan also made multiple attempts to obtain 
additional information from the provider without success. Based on this information, we decided that Medicare 
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services coded as 81191, 81317, 81321, 81295, 81298, 81206, 81210, 81235, 81272, 
81275, 81276, 81292, 81301 and 81311 provided June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation of the sacroiliac joint (64625) 
provided on October 13, 2021. 
 
You asked the Plan to pay for the radiofrequency ablation of the sacroiliac joint (64625). You say that 
providers must provide services to beneficiaries that Original Medicare Part A and B cover. You say that 
Medicare Part B covers CPT code 64625, the criteria have been met, and the service should be reimbursed. The 
Plan denied your request. The Plan says radiofrequency ablation used for sacroiliac joint pain is considered not 
medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. 
 
  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 radiofrequency ablation of the sacroiliac 
joint (64625). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that radiofrequency ablation of the lateral sacral branches 
is considered experimental/ investigational because of the wide variation in efficacy reported in the literature. 
 
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 radiofrequency ablation of the sacroiliac joint (64625) have not been met. 
Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation of the sacroiliac joint 
(64625) provided on October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 18, 2021, to July 
20, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services provided were medically 
necessary. You also say that payment should be made despite lack of authorization. The Plan denied your 
request. The Plan says that the inpatient 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 record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
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 from July 18, 2021, to July 20, 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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for imaging services provided to the enrollee on October 19, 2021, through 
October 21, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the procedure is inappropriately coded, and you are required to code to the highest level of 
specificity. 
 
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 has not substantiated their denial in this case. The plan has denied the 
services for not being billed correctly. However, they have not stated exactly what was billed incorrectly, and 
how the provider could correct the claim. Therefore, we decided that the Plan has to pay for imaging services 
provided to the enrollee on October 19, 2021, through October 21, 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 procedure codes 36012-Q6-59, 37248-Q6-59, and 75820-
QR-59 billed for date of service March 24, 2021. 
 
You asked the Plan to pay for procedure codes 36012-Q6-59, 37248-Q6-59, and 75820-QR-59. You say that 
the records support the services as billed. The Plan denied your request. The Plan says code 36012-Q6-59 is not 
supported by the medical record.  The Plan also says that codes 37248-Q6-59 and 75820-Q6-59 are inclusive to 
another code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
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 36012-Q6-59, 37248-Q6-59, and 75820-QR-59. Our reviewer says that payment for these codes is not supported by the medical record. Our reviewer 
found that you billed the following procedure codes: Current Procedural Terminology (CPT) 37248, which is  
Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and 
radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial 
vein; CPT 75820, which is Venography, extremity, unilateral, radiological supervision and interpretation; and 
CPT code 36012, which is Selective catheter placement, venous system; second order, or more selective, 
branch (eg, left adrenal vein, petrosal sinus). For CPT 37248, the operative report does not include 
documentation to support this service was performed at different anatomic site, or different organ, or different 
anatomic regions, and therefore modifier -59 is not supported. For CPT 75820. The operative report does not 
include documentation to support service was performed at different anatomic site, or different organ, or 
different anatomic regions, and therefore modifier -59 is not supported. For CPT 36012,  the procedure report 
does not include documentation to support venous catheter placement second order or more.  To cite the 
operative report "Under ultrasound guidance and after administration of local anesthesia, the right superficial 
femoral vein was accessed with a 5 French microcatheter system.  A stiff glidewire was advanced to the right 
common iliac, IVC and right subclavian vein."  Per the National Correct Coding Initiative Policy Manual "A 
second order branch of the vena cava (36012) is any vein draining into a first order branch.  Therefore, this 
procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 36012-Q6-59, 37248-Q6-59, and 75820-QR-59 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 36012-Q6-59, 37248-Q6-59, 
and 75820-QR-59 billed for date of service March 24, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve PuraPly skin substitute for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are not enough medical studies to show that this treatment works. 
 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found this request is needed to facilitate healing and avoid serious complications 
 
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 pre-
approve PuraPly skin substitute for the enrollee.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eye exam services (92014 and 92015) provided 
on October 22, 2021. 
 
You asked the Plan to pay for the routine eye exam services (92014 and 92015). You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you are covered for 
1 routine eye exam every year under the Plan's supplemental vision benefit. The Plan says they paid for the 
routine eye exam you received on February 18, 2021. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The Plan contract clearly covers under the supplemental vision 
benefit 1 routine eye exam per year. The file shows that the Plan paid for the routine eye exam you received on 
February 18, 2021. Based on this information, we decided that the Plan's rules for coverage of the routine eye 
exam services (92014 and 92015) received on October 22, 2021 have not been met. Therefore, we decided that 
the Plan does not have to pay for the routine eye exam services (92014 and 92015) provided on  
October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the microsurgical techniques (69990) provided on September 
24, 2021. 
  You asked the Plan to pay for the microsurgical techniques (69990). The Plan denied your request. The Plan 
says CPT code 22585 was overturned, and CPT code 69990 remains denied as a modifier is not allowed to 
bypass the 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 69990 
is a column II code to column I code 22854. This claim has cannot be billed with a 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 microsurgical techniques (69990) provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program provided on 
December 21, 2021. 
 
You asked the Plan to waive the copayment for the ophthalmological services. The Plan denied your request. 
The Plan says the claim paid with the correct $35 copayment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Vision Care, Medicare-covered eye exams to diagnose and treat diseases and conditions of the 
eye.  
 You have been asked to pay a $35 copayment for the ophthalmological services. The ophthalmological services 
falls within the Vision Care, Medicare-covered eye exams to diagnose and treat diseases and conditions of the 
eye benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for ophthalmological services: 
medical examination and evaluation, with initiation or continuation of diagnostic and treatment program 
provided on December 21, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided from January 5, 2021, to January 9, 
2021, at the diagnosis related group (DRG) billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG billed. You say that the claim was 
billed correctly and should be paid as billed. The Plan denied your request. The Plan says that the DRG billed 
was downgraded because the principal diagnosis of I21.4 (non-ST Elevation (NSTEM) myocardial infarction) 
was not supported in the medical record. 
 
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 principal diagnosis of I21.4 (non-ST Elevation 
(NSTEM) myocardial infarction). 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. Our reviewer says that a principal diagnosis of I21.4 (non-ST Elevation (NSTEM) 
myocardial infarction) is supported in the medical record. Our physician reviewer found the enrollee was a then 
77 year old female with a history of chronic obstructive pulmonary disease/asthma and recent COVID-19 
infection who presented to the Emergency Room with a 1-week history of cough with chest pain and shortness 
of breath. She was evaluated and diagnosed with acute hypoxic respiratory failure secondary to non STEMI. 
She was evaluated by Cardiology and underwent coronary catheterization which demonstrated normal coronary 
arteries. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided from January 5, 2021, to January 9, 2021, at the diagnosis related group (DRG) 
billed.   
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 17, 2021. 
 
You asked the Plan to pay for the home health services. You say that you billed these services correctly. The 
Plan denied your request. The Plan says you billed with an invalid Type of Bill code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill home health services with the 
appropriate Type of Bill code. For this code, the first digit is a leading zero.  The second digit is for the type of 
facility. The third digit is for the type of care, and the fourth digit is the sequence of the bill in the episode of 
care.  A fourth digit of 3 is not valid for Prospective Payment System bills. 
 
In this case, you billed with a Type of Bill code of 0323. As noted above, a fourth digit of 3 (which is what you billed), is not valid for Prospective Payment System bills. We looked at the file and Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided on October 17, 
2021.