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

 
We decided that the Plan does not have to pay for lab services (0037U) provided on September 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and is 
supported in the medical record. 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 lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (0037U) provided on September 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) G0416 and 88342 billed for date of 
service September 16, 2021. 
 
You asked the Plan to pay for procedure code(s) G0416 and 88342. The Plan denied your request. The Plan 
says these codes are included in the facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) G0416 and 88342. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) G0416 and 
88342. Based on this information, we decided that Medicare rules for coverage of procedure code G0416 and 
88342 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
G0416 and 88342 billed for date of service September 16, 2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 57155, 77295, 77771, 
77290, and 77334. We decided that the Plan does not have to pay for the services described by procedure 
code(s) 77300.   
You asked the Plan to pay for code 77300, described as radiation therapy dose plan prescribed by the treating 
physician. You say that the claim was billed properly and should be paid. The Plan says that payment for code 
77300 is bundled into payment for code 77771. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 57155, 77295, 77771, 
77290, and 77334.  
 
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. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 57155, 77295, 77771, 77290, 
and 77334.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
77300. 
 
The Plan follows Medicare rules. Medicare rules say that the National Correct Coding Initiative (NCCI) was 
developed to prevent inappropriate payment of services that should not be reported together. NCCI edits are 
organized in a Column I/Column 2 table. Each edit is a pair of codes that should not be reported together. If a 
provider reports two codes of an edit pair, only the Column 1 code is payable. For edits with a modifier 
indicator of 0, the Column 2 code cannot be paid regardless of whether a modifier is used. You can find this in 
the NCCI Manual, Chapter I. 
 
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 described by procedure code(s) 77300 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
77300. 
 
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 an inpatient admission for a right shoulder reverse 
arthroplasty. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the preoperative clearance and comorbid conditions suggest that the 
procedure could initially be performed on an ambulatory/observation basis. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the requested reverse total shoulder arthroplasty is documented to have been 
supported. However, detailed documentation is not evident regarding a significant past and/or current medical 
history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient 
stay. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the record does not show that at the time of inpatient 
admission, the admitting physician reasonable expected that the patients 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 not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient admission for a right shoulder reverse arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99213 provided on September 8, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable as 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 99213 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is 
spent on the date of the encounter. 
 
We find that CPT code 99213 is not supported in the medical record. Specifically, this service was provided 
within the global period of procedure code 11424 (excision, benign lesion including margins, except skin tag 
(unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm) provided on 
August 29, 2022. This means code 99213 is not separately payable as billed. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit coded 99213 provided on 
September 8, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient surgery provided on May 5, 2022. 
 
You asked the Plan to pay for the outpatient surgery. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says that the payment for this service is included in the fee for the procedure. 
 
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. Review of the file shows that the Plan has denied this service as "the payment 
for this service is included in the fee for the procedure". The file does not include documentation to support 
what procedure this service should be included in. In addition, the documentation does not provide any 
Medicare rules to support this denial. The Plan did not substantiate their denial. Therefore, we decided that the 
Plan has to pay for the outpatient surgery provided on May 5, 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 lab services (80307, G0483) provided on August 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. 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 lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (80307, G0483) provided on August 16, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Reclast (zoledronic acid) injections. 
 
You asked the Plan to pre-approve the Reclast injections. You say that this treatment is medically necessary. 
The Plan denied your request. The Plan says that the records do not include sufficient documentation that all 
the potential contraindications to this drug have been evaluated and ruled out. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Reclast injections. Our reviewer 
says that the requested use of Reclast is found to be medically reasonable and necessary. Our physician 
reviewer found the enrollee has a diagnosis of Age-related osteoporosis with current pathological fracture with 
delayed healing. The enrollee has osteoporosis which is in the severe range in the right femur. The enrollee has 
had multiple rib fractures in the past. The enrollee's history is also notable for gastrointestinal reflux with 
esophagitis. 
 
The available documentation supports that Reclast is medically reasonable and necessary for the treatment of 
Age-related osteoporosis in this enrollee. Available clinical studies do not demonstrate a contraindication for 
Reclast in this enrollee, so it is also likely to be safe and effective. 
 
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 Reclast injections have been met. Therefore, we decided that the Plan has to 
pre-approve Reclast (zoledronic acid) injections.  
 
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 the home health services provided from April 28, 2022, to 
May 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 28, 2022, to May 
27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 75710 provided on September 13, 2022. 
 
You asked the Plan to pay for procedure code 75710. You say that the medical records support the use of 
modifier 59 with code 75710. The Plan denied your request. The Plan says the medical records do not support 
the use of modifier 59 with code 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. 
 
In this case, we have confirmed that code 75710 is a column II code to column I code 37227; however, 75710 
was billed with a modifier.  
 
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 code 75710. Our reviewer says that the medical 
records do not support the use of modifier 59 with code 75710. Our reviewer found the documentation does not 
support CPT 75710 -59 as a distinct procedural service. The operative report describes an angiography with 
intervention in same anatomical area. Per NCCI Policy "Open and percutaneous interventional vascular 
procedures include operative angiograms and/or venograms, which shall not be separately reported as 
diagnostic angiograms/venograms".  In this case, modifier -59 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 code 75710 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 75710 provided on September 13, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 96116 and 96121 for date of service, April 25, 2022. 
 
You asked the Plan to pay for codes 96116 and 96121. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 96116 and 96121 are not supported in the medical record. Specifically, these services 
were billed with diagnosis F01.50 (Vascular dementia, unspecified severity, without behavioral disturbance, 
psychotic disturbance, mood disturbance, and anxiety). This diagnosis code is a "code first" diagnosis. This 
diagnosis is not acceptable as a primary diagnosis. Therefore, the services are not payable as billed. Based on 
this information, we decided that Medicare rules for coverage of codes 96116 and 96121 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 96116 and 96121 for date of service, April 
25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81479) provided on January 15, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and 
appropriate. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for laboratory services was not filed until October 4, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for laboratory services (81479) provided on January 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service August 10, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that the claim was billed properly and should be 
paid. The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 
12002. 
 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 93042 
is a column II code to column I code 12002. 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 procedure code 93042 billed for date of service August 10, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on October 20, 2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was necessary and is supported as billed. 
The Plan denied your request. The Plan says that this code is not supported in the medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the record supports that drugs 
from between 15 and 21 classes were tested in this case, including alcohol biomarkers, amphetamines, 
benzodiazepines, buprenorphine, cannabinoids (natural), fentanyls, gabapentin (non-blood), methadone, 
methylenedioxyamphetamines, methylphenidate, opiates, opioids and opiate analogs, oxycodone, 
phencyclidine, pregabalin, tapentadol and tramadol. Based on this information, we decided that Medicare rules 
for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive drug 
testing (G0482) provided on October 20, 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: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on September 19, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service was necessary and is supported as billed. 
The Plan denied your request. The Plan says that this service is not supported in the medical record. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the record supports that 
between 15 and 21 drug classes were tested in this case, including alcohol biomarkers, amphetamines, 
benzodiazepines, buprenorphine, cannabinoids (natural), cocaine, fentanyls, gabapentin (non-blood), heroin 
metabolite, methadone, methylenedioxyamphetamines, methylphenidate, opiates, opioids and opiate analogs, 
oxycodone, phencyclidine, pregabalin, skeletal muscle relaxants, tapentadol and tramadol. Based on this 
information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided 
that the Plan has to pay for definitive drug testing (G0482) provided on September 19, 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.