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

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on July 25, 
2022. 
 
You asked the Plan to pay for the blood smear 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. 
 
In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
 
 We find that CPT code 85060 is not supported in the medical record. Specifically, this code was billed with a 
place of service of 22 (on campus-outpatient hospital). No payment is recognized for code 85060 furnished to 
hospital outpatients or non-hospital enrollees. Therefore, place of service 22 is not an appropriate place of 
service for code 85060. Based on this information, we decided that Medicare rules for coverage of the blood 
smear services have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear 
services coded 85060 provided on July 25, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an outpatient visit provided on June 14, 2022. 
 
You asked the Plan to pay for the outpatient visit. You say that the medical records provided show the services 
were medically necessary. The Plan denied your request. The Plan says that we do not have the information we 
need to consider this charge. 
 
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 stated what information the Plan still needed after 
the medical records were provided with the appeal case to substantiate their denial. Therefore, we decided that 
the Plan has to pay for an outpatient visit provided on June 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear, peripheral, interpretation by physician with 
written report (CPT 85060) provided August 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please review and reprocess for payment. 
The Plan denied your request. The Plan says the claim was billed with an inappropriate place of service 22 
(Outpatient Hospital). 
 
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 85060 is blood smear, peripheral, interpretation by 
physician with written report, 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, CPT code 85060 has an 
indicator 8. The physician interpretation is paid through the clinical laboratory fee schedule payment for the 
clinical laboratory test. This indicator identifies the professional component of clinical laboratory codes for 
which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. 
No TC billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, 
generally through the PPS rate.  You can find this in the Claims Processing Manual, Chapter 23, Section 50.6. 
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 the blood smear, peripheral, 
interpretation by physician with written report (CPT 85060) provided August 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 14, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says 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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the record did not show that at the time of the inpatient admission, the admitting 
physician reasonably expected that the enrollees necessary hospital care (including earlier emergency 
department 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 the acute inpatient hospital care provided on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gauze (A6219) provided on September 16, 2022. 
 
You asked the Plan to pay for the gauze. You say that the claim should be paid. The Plan denied your request. 
The Plan says this service is bundled into payment with another service that was already paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code A6219 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A6219 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the gauze have not been met. Therefore, we decided that the Plan does not have to pay for the 
gauze (A6219) provided on September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services billed with code 50546 for August 8, 
2022. 
 
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 the code was not billed correctly. 
 
The plan must follow Medicare rules. The rules say that anatomical modifiers are required for procedures 
performed on different anatomical sites. 
 
We looked at the file and Medicare rules. The file shows that code 50546 was not billed with a required 
anatomical modifier. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services billed 
with code 50546 for August 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for open procedures on bones of lower leg, ankle, and foot; 
not otherwise specified (code 01480QX) provided on July 29, 2022. 
 
You asked the Plan to pay for anesthesia for open procedures on bones of lower leg, ankle, and foot; not 
otherwise specified. You say that this provider is eligible to provide anesthesia services and the claim was 
billed correctly. The Plan denied your request. The Plan says that the Plan reimburses ASA codes to anesthesia 
providers only. Therefore, this code is not eligible for payment. 
 
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 provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for anesthesia for open 
procedures on bones of lower leg, ankle, and foot; not otherwise specified (code 01480QX) provided on  
July 29, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed with codes 80307 and G0480 for 
August 10, 2022. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing billed with codes 80307 and G0480 for August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on November 2, 2022. 
 
You asked the Plan to pay for the annual wellness visit. The Plan denied your request. The Plan says the benefit 
limit has been reached. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on  
November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for excision, tumor, soft tissue of neck or 
anterior thorax, subfascial (code 21556) provided on February 24, 2022. 
 
You asked the Plan to pay for physician's services for excision, tumor, soft tissue of neck or anterior thorax, 
subfascial. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the 
services to confirm that Medicare coverage criteria has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of physician's services for excision, 
tumor, soft tissue of neck or anterior thorax, subfascial have been met. Therefore, we decided that the Plan does 
not have to pay for physician's services for excision, tumor, soft tissue of neck or anterior thorax, subfascial 
(code 21556) provided on February 24, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0242U) provided on October 6, 2021.

You asked the Plan to pay for the lab services. You say that this is a covered test which was provided for an approved indication. 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 (0242U) provided on October 6, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) provided 
to the enrollee on August 23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 99284 is more correct for the services, per the documentation provided. 
 
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 99285 is "Emergency department visits for the evaluation 
and management of a patient, which requires these three key components within the constraints imposed by the 
urgency of the patients clinical condition and/or mental status: a comprehensive history, a comprehensive 
examination; and medical decision making of high complexity; counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patients and/or familys needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee presented with a 
subacute complaint. His vitals and examination were non-actionable. The enrollees work-up was benign and 
he was deemed to be stable for discharge.  Decision making was not highly complex. The presenting problem 
did not pose an immediate threat to life or physiologic function. As such, the billing of CPT 99285 is not 
supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) provided to the enrollee on August 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for angiography, extremity, unilateral, radiological supervision 
and interpretation provided to the enrollee on June 6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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 75710 is "Angiography, extremity, unilateral, 
radiological supervision and interpretation." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support the use of CPT 75710. This code is used to indicate the supervision and interpretation of an extremity 
angiogram. No interpretation of either an upper or lower extremity angiogram is provided in the medical 
records. Therefore, there is insufficient documentation in the medical record to justify coverage of CPT 75710. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for angiography, extremity, unilateral, radiological supervision and interpretation provided to the 
enrollee on June 6, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) provided 
to the enrollee on March 16, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says normally a lower-level emergency department code would be reported for a non-emergency 
condition. 
 
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 99285 is "Emergency department visits for the evaluation 
and management of a patient, which requires these three key components within the constraints imposed by the 
urgency of the patients clinical condition and/or mental status: a comprehensive history, a comprehensive 
examination; and medical decision making of high complexity; counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patients and/or familys needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee presented with a 
straightforward complaint. A comprehensive history was not documented. Decision making was of low 
complexity. The presenting problem did not pose an immediate threat to life or physiologic function. As such, 
the billing pf CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) provided to the enrollee on March 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the ventilator is not necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found the enrollee improves with bilevel positive airway pressure (BiPAP) as an inpatient and may 
benefit from BiPAP with average volume-assured pressure support (AVAPS) during sleep as an outpatient. 
There is no indication in the record that this has been tried and failed as an outpatient. Medicare does not cover 
a home ventilator when used as BiPAP. 
 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says the requested acupuncture treatments are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Plan rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
continued acupuncture treatments are not medically necessary. Our physician reviewer found that significant 
improvement of your pain has not been demonstrated or documented. Therefore, your request is considered not 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and the Plans rules. Based on this information, we decided that 
the Plans rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued acupuncture treatments.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70547 billed for date of service September 18, 2022.

You asked the Plan to pay for procedure code 70547. You say that claim was billed correctly and should be paid The Plan denied your request. The Plan says payment for code 70547 is bundled into payment for code 70540.

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 70547 is a column II code to column I code 70540. 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 70547 billed for date of service September 18, 2022.