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

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) provided 
to the enrollee on June 1, 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 Current Procedural Terminology (CPT) code 99152 59 (1 Unit) remains 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 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 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 review has determined that 
the records do not support that CPT 99152 was rendered in this case. The records do not document the presence 
of an independent trained observer. 
 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 moderate sedation services (procedure code 99152) provided to the enrollee on June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the IsoPSA test (81599) provided on July 13, 2022. 
 
You asked the Plan to pay for the IsoPSA test. You say that this test was medically necessary to assist in the 
development of the enrollees treatment plan. The Plan denied your request. The Plan says this test is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. Based on this 
information, we decided that Medicare rules for coverage of the IsoPSA test have not been met. Therefore, we 
decided that the Plan does not have to pay for the IsoPSA test (81599) provided on July 13, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visits provided from February 2, 2022, to July 20, 2022. 
 
You asked the Plan to pay for the physician services. You say that the services should be covered. The Plan 
denied your request. The Plan says that the services in this case are incidental to another service. 
 
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 file does not support the Plan's reason for denial. The provided 
documentation does not support that the services in this case are incidental to other services. Therefore, we 
decided that the Plan has to pay for the office visits provided from February 2, 2022, to July 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: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (80307, G0483) billed for date of service 
November 15, 2021. 
 
You asked the Plan to pay for drug testing. You say that the services at issue have been reported and billed 
correctly. The Plan denied your request. The Plan says the available records do not support the services billed. 
 
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 drug testing have been met. 
Specifically, the case record does not contain the physician order for the drug testing at issue. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for drug testing (80307, G0483) billed for date of service November 
15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 and 99292 billed for date of service 
April 8, 2022. 
 
You asked the Plan to pay for procedure code 99291 and 99292. You say that you disagree with the denial. The 
Plan denied your request. The Plan says payment for codes 99291 and 99292 is bundled into payment for code 
31500. 
 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 codes 
99291 and 99292 are column II codes to column I code 31500. 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 99291 and 99292 billed for 
date of service April 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service June 4, 2022. 
 
You asked the Plan to pay for procedure code 36000. You say that this should be paid. The Plan denied your 
request. The Plan says procedure code 36000 is considered bundled and not separately payable. 
 
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 36000 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service June 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tendon sheath incision procedure (26055). 
 
You asked the Plan to pre-approve a tendon sheath incision. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a tendon sheath incision. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee is being treated for trigger finger of the right thumb. The enrollee was provided 
an injection in the right thumb on December 6, 2022, with no additional follow-ups provided to document the 
results from that injection. The peer-reviewed literature supports the failure of conservative measures prior to 
surgical release. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tendon sheath incision have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a tendon sheath incision procedure (26055).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on August 10, 2022. 
 
You asked the Plan to pay for ConfirmMDx testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare covers ConfirmMDx testing when an enrollee is being 
considered for a repeat biopsy due to persistent or elevated cancer-risk factors. The case file does not show that 
the enrollee was being considered for a repeat biopsy. Based on this information, we decided that Medicare 
rules for coverage of ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not 
have to pay for ConfirmMDx testing (81551) provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable battery-operated oxygen concentrator aerator 
backpack. 
 
You asked the Plan to pre-approve a portable battery-operated oxygen concentrator aerator backpack. You say 
that you need the device as you have difficulty walking, have carpel tunnel, arthritis, and needs portable 
oxygen to take to the doctors as your other device is too large. The Plan denied your request. The Plan says you 
do not have a valid prescription for the device. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, a valid prescription, or relevant medical records which 
support medical necessity for the requested device in this case. The record shows that your pulmonologist has 
advised the Plan that they did not order the portable device and you would have to undergo certain testing 
before an order for this device would be written. Therefore, we decided that the Plan does not have to pre-
approve a portable battery-operated oxygen concentrator aerator backpack.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Hematology Profile (81455) provided on September 12, 2022. 
 
You asked the Plan to pay for the Hematology Profile. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that there was insufficient information to verify the medical necessity 
of the requested service. 
 
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. We find that there are no medical records provided in the appeal to review the 
medical necessity of the requested testing. The Plan has not provided any documentation showing that any 
effort was made to obtain the missing information. Therefore, we decided that the Plan has to pay for the 
Hematology Profile (81455) provided on September 12, 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: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 26, 2022, 
through March 29, 2022, and billed with diagnosis codes A41.9 and N17.0. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.9 and secondary diagnosis N17.0 is supported by the records provided. The Plan denied your 
request. The Plan says the documentation submitted does not support primary diagnosis A41.9 and secondary 
diagnosis N17.0 
 
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 primary diagnosis code A41.9, Sepsis, unspecified 
organism, and secondary diagnosis code N17.0, Acute kidney failure with tubular necrosis. 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 records submitted do not support diagnosis code A41.9, Sepsis, unspecified 
organism as a primary diagnosis code and N17.0, Acute kidney failure with tubular necrosis as a secondary 
diagnosis code. Our physician reviewer found the member was admitted to the hospital with abdominal pain 
and leukocytosis. The member was diagnosed and treated for acute cholecystitis. The documentation indicates 
the creatinine was elevated but the member has chronic kidney disease without a known baseline creatinine 
level. The creatinine improved with intravenous Ceftriaxone. There was no evidence of life-threatening organ 
dysfunction due to dysregulated host response to an infection or persistent hemodynamic instability. The 
documentation does not indicate that the diagnostic work-up and treatment support the primary diagnosis code 
A41.9 (Sepsis, unspecified organism) and the secondary diagnosis code N17.0 (Acute kidney failure with 
tubular necrosis).  
 
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 March 26, 2022, through March 29, 2022, and billed with diagnosis 
codes A41.9 and N17.0.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 20, 2022, 
through March 23, 2022, and billed with diagnosis code N17.0. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
secondary diagnosis N17.0 is supported by the records. The Plan denied your request. The Plan says the 
documentation submitted does not support secondary diagnosis of N17.0. 
 
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 secondary diagnosis code N17.0 Acute kidney 
failure with tubular necrosis. 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 secondary diagnosis code N17.0 
Acute kidney failure with tubular necrosis is not appropriate. The diagnosis of N17.0 Acute kidney failure with 
tubular necrosis) is documented in the nephrology progress notes, however no sufficient supporting 
documentation was not found within the medical record to validate this as a secondary diagnosis. Our physician 
reviewer found the member was diagnosed with myocardial infarction and started on heparin and intravenous 
Ceftriaxone; hyponatremia was noted due to dehydration. The members creatinine level was at 1.5 from 
baseline of 0.9 which was suspected due to a contrast nephropathy following a heart catheterization procedure. 
The members sodium and kidney function improved with fluids, although the member had evidence of acute 
kidney failure due to a significant rise in creatine from baseline, there was insufficient objective evidence 
provided for specifically tubular necrosis as the cause. The documentation did not confirm acute tubular 
necrosis such as casts in urine or based on the biopsy. Using the acute tubular necrosis diagnosis without 
evidence defaults to a more general diagnosis such as acute kidney failure.  
 
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 March 20, 2022, through March 23, 2022, and billed with diagnosis 
code N17.0.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the upper 
extremity. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary for a history of left 
shoulder pain. The Plan denied your request. The Plan says there are no results of plain x-rays available. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
enrollee has a six-year history of non-traumatic left shoulder pain. During the encounter on 8/25/22, no detailed 
left shoulder physical exam was performed. In particular, no provocative maneuvers were done. There are no 
plain x-ray results. There are no red flags and no attempt at a six-week trial of conservative management, 
including physical therapy. The medical necessity of the requested MRI of the left shoulder has not been 
established in the submitted records. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the upper extremity.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that these tests were medically necessary and should be 
paid. 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 provided on February 22, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services provided on May 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that a timely decision 
was not made. 
 
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 the billed CPT codes are supported in the medical record. Specifically, as the case file shows that 
the Plan would have overturned these services if they had made the decision in time, the records support the 
services billed. 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 pay for the drug testing services provided on May 16, 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the V-GO 30 kit disposable. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says drugs and supplies used with disposable drug delivery systems are non-covered items. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the V-GO 30 kit disposable.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance used with a therapeutic CGM device 
(K0553) provided August 21, 2022. 
 
You asked the Plan to pay for the CGM supply allowance. You say that the enrollee is long standing diabetic 
with hyperglycemia and fluctuating blood sugar levels. The enrollee owns the K0554 since November 18, 
2022, and the K0553 Freestyle Libre sensors is needed every 30 days. The Plan denied your request. The Plan 
says services not documented in the enrollee's medical records. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. Specifically, the medical records included the proof of delivery, however, the date of service of August 21, 2022, does not match the 
delivery/shipping date or the date the label was created. The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for supply allowance used with a therapeutic CGM device (K0553) provided August 21, 2022.