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

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 25, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for 
date of service January 17, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360, and 88381. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says these 
services were not billed in accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that procedure codes 88341, 88342, 88360, and 88381 are physician pathology services which have 
both professional components (PC) and technical components. These services were not billed with modifier 26 
to indicate that only the professional component payment is requested. This means that payment is requested 
for both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
outpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88341, 88342, 88360, and 88381 billed for date of service January 17, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services identified with codes 99291 and 
99222 provided on May 29, 2022. 
 
You asked the Plan to pay for the critical care services. 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 99291 and 99222 are not supported in the medical record. Specifically, these codes for 
critical care services are not payable when billed on the same dates of service as hospital emergency 
department services when provided by the same physician or two physicians in the same group with the same 
specialty. This means this claim is not payable as billed. Based on this information, we decided that Medicare 
rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not 
have to pay for the critical care services identified with codes 99291 and 99222 provided on May 29, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for a psychiatric diagnostic evaluation without medical services provided 
on February 11, 2022. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that this provider is eligible to 
provide services for Medicare patients and this provider does receive payment from Medicare. The Plan denied 
your request. The Plan says that this provider type is not eligible in the Medicare program. 
 
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 has not provide a rule or documentation to support the 
denial. Therefore, we decided that the Plan has to pay for a psychiatric diagnostic evaluation without medical 
services provided on February 11, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillofacial computed tomography (CT) scan (70486) 
provided on July 6, 2022. 
 
You asked the Plan to pay for a CT scan. You say that this is covered and was medically necessary. The Plan 
denied your request. The Plan says this cannot be paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that composite ambulatory payment classifications 
(APCs) provide a single payment for a comprehensive diagnostic and/or treatment service that is defined, for purposes of the APC, as a service typically reported with multiple codes. Services mapped to composite APCs 
are assigned status indicator Q3.  
 
We looked at the file and Medicare rules. The code at issue has a status indictor of Q3, meaning it is assigned 
to an APC and a single payment is made for multiple codes. This code is not separately payable from the 
composite payment. Based on this information, we decided that Medicare rules for coverage of a CT scan have 
not been met. Therefore, we decided that the Plan does not have to pay for a maxillofacial computed 
tomography (CT) scan (70486) provided on July 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 24, 2021 to 
March 6, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis of J15.6 (pneumonia due to other gram-negative bacteria) is supported in the medical record and was 
billed appropriately. The Plan denied your request. The Plan says the diagnosis of J15.6 (pneumonia due to 
other gram-negative bacteria) is not supported in the medical record and diagnosis J18.9 (pneumonia, 
unspecified organism) should have been billed instead. Without microbiological confirmation of a gram-
negative organism, gram-negative pneumonia cannot be confirmed. As a result, a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with the diagnosis of J15.6 (pneumonia due to other 
gram-negative bacteria). We asked our physician reviewer to carefully review the case file and apply the 
relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient 
hospital services at the DRG originally billed. Our reviewer says that the diagnosis of J15.6 (pneumonia due to 
other gram-negative bacteria) is not supported in the medical record. Our physician reviewer found the 
documentation indicates that the enrollee was a then, 66-year-old male who presented with complaints of body 
aches, chills, shortness of breath, and cough. The patient had a past medical history of lymphoma with recent 
chemotherapy, aortic stenosis, diabetes mellitus type 2, immunosuppression, dyslipidemia, testicular cancer, 
gastroesophageal reflux disease, and obstructive sleep apnea. A computed tomographic (CT) angiogram of the 
chest was obtained which ruled out pulmonary embolism but did note right upper and lower lobe infiltrates. 
The patient was diagnosed with multifocal pneumonia and started on multiple intravenous antibiotics. While 
the physician indicated a diagnosis of Gram-negative pneumonia in the documentation clarification request, 
the clinical evidence did not support the condition. Gram-negative pneumonias occur most often in individuals 
who are debilitated, immunocompromised, or recently hospitalized. Individuals living in long-term care 
facilities where other residents are intubated are also at risk for these infections.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 24, 2021 to March 6, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for codes 63056, 63057, 20939, and 20937 provided on June 10, 2022. 
 
You asked the Plan to pay for codes 63056, 63057, 20939, and 20937. You say that these codes are 
documented. The Plan denied your request. The Plan says that these codes 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. In this case, the CPT Code Manual definition of 
code 63056 is transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, 
herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) 
(eg, far lateral herniated intervertebral disc). The definition of 63057 is transpedicular approach with 
decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; 
each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure). The 
definition of 20939 is bone marrow aspiration for bone grafting, spine surgery only, through separate skin or 
fascial incision (List separately in addition to code for primary procedure). The definition of 20937 is autograft 
for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) 
(List separately in addition to code for primary procedure). 
 
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 codes 63056, 63057, 20939, and 20937. Our reviewer says 
that these codes are supported. Our reviewer found these services are documented in the highlighted portions of 
the operative report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 63056, 63057, 20939, and 20937 have been met. Therefore, we decided 
that the Plan has to pay for codes 63056, 63057, 20939, and 20937 provided on June 10, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 16, 2022, to May 
18, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that 
the inpatient care 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 that all tests in the emergency department (ED) were negative for any acute process. The 
enrollee was appropriate for observation as this was a new onset with no previous syncope issues, or diagnosis 
related to syncope, and a relatively healthy history. The enrollee was subsequently worked up with negative 
results and no intervention required and was discharged to home in stable condition on May 18, 2022. The 
record shows that at the time of inpatient admission the admitting physician reasonably expected that the 
enrollee'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 May 16, 2022, to May 18, 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 procedure code 88321 billed for date of service April 1, 
2022. 
 You asked the Plan to pay for procedure code 88321. You say that you performed two units of this service on 
this date. 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 88321 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 88321 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88321 billed for date of service April 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service March 7, 
2022, to April 5, 2022. 
 You asked the Plan to pay for home health services. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, for all beneficiaries receiving HH services in 
2021 whose services will continue in 2022, the HHA shall submit an NOA with a one-time, artificial 
'admission' date corresponding to the "From" date of the first period of continuing care in 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the admission date on the claim for the 
services at issue does not correspond to the admission date on the received NOA. Therefore, we decided that 
the Plan does not have to pay for home health services billed for dates of service March 7, 2022, to April 5, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96372 and 73030 billed for date of service 
August 1, 2022. 
 
You asked the Plan to pay for procedure codes 96372 and 73030. You say that the code is covered by CMS fee 
schedule and medically necessary The Plan denied your request. The Plan says payment for code 96372 and 
73030 is bundled into payment for code 99284. 
 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 96372 
and 73030 is a column II code to column I code 99284. 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 codes 96372 and 73030 billed for date 
of service August 1, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would like reconsideration because the services 
are medically necessary. The Plan denied your request. The Plan says that a SNF admission is not medically 
necessary, and you can get the care you need in another setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you have documented skilled nursing needs in the form of a new feeding tube. Daily 
skilled services are required to establish a maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve SNF care.  
   
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a revision of breast reconstruction. 
 
You asked the Plan to pre-approve the revision. You say that this is medically necessary due to asymmetry. 
The Plan denied your request. The Plan says this procedure is for cosmetic indications only. 
 
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 revision. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has a history of breast surgery and reconstruction 
in 2010. The record provided indicates that the enrollee seeks symmetry. The records provided indicate that a 
left sided mastopexy and reduction is contemplated in the uninvolved breast.  A subsequent note indicates that 
fat grafting to both breasts is being considered.  The record indicates that the enrollee has already undergone reconstructive surgery a decade ago. The record as provided is insufficient to determine the medical necessity 
and reasonableness as defined by Medicare rules, of the requested service. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. 
 
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 revision have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a revision of breast reconstruction.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrodesis, triple (28715) diagnostic bone marrow aspiration 
(38820) provided November 15, 2021. 
 
You asked the Plan to pay for the surgical services. You say that there are no network providers with similar 
credentials and expertise for services provided in the enrollee's area at the time the provider was assigned. The 
Plan denied your request. The Plan says services not payable per modifier description. Medicare cannot 
reimburse a surgical assistant's services if the assistant is an unlicensed practitioner and/or does not qualify to 
be a Medicare provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for arthrodesis, triple (28715) diagnostic 
bone marrow aspiration (38820) provided November 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray on July 7, 2022. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you would like to appeal the cost share. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $40 
copayment for an x-ray.  
 
You have been asked to pay a $40 copayment for an x-ray. This item/service falls within the Outpatient 
diagnostic tests and therapeutic services and supplies 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 an x-ray on July 7, 2022.