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

 
We decided that the Plan has to pay for the hyperbaric oxygen therapy (HBOT) billed for date of service March 
27, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the records 
do not include the condition or diagnosis.  
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is covered under certain 
medical indications. 
 
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 billed services. Our physician reviewer 
found that the enrollee has prostate cancer treated with radiation in 2013. He is currently being treated with 
Lupron and Nubeqa. He developed hemorrhagic radiation cystitis confirmed by cystoscopy. Hyperbaric oxygen 
therapy is considered medically necessary for radiation induced injuries such as hemorrhagic radiation cystitis 
as is the case with this enrollee. Clinical studies have shown that hyperbaric oxygen therapy is very effective 
for hemorrhagic radiation cystitis. Therefore, the billed services are supported. 
 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 billed services have been met. Therefore, we decided that the Plan has to 
pay for the hyperbaric oxygen therapy (HBOT) billed for date of service March 27, 2023.  
 
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 reverse shoulder joint replacement surgery and 
associated procedures (76942, 64450, 54415 and 23472). 
 
You asked the Plan to pre-approve reverse shoulder joint replacement surgery and associated procedures. You 
say that these services are medically necessary and appropriate for this enrollee. The Plan denied your request. 
The Plan says these services are not medically necessary as there is no evidence that the enrollee has tried 
physical therapy for the left shoulder or that physical therapy is contraindicated. 
 
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 reverse shoulder joint replacement 
surgery and associated procedures. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative care measures is 
not evident. There is no clear indication that the enrollee has had left shoulder physical therapy. Moreover, the 
provided diagnostic imaging did not corroborate significant glenohumeral degenerative changes. There are 
limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this 
clinical setting. No compelling rationale is presented, or extenuating circumstances noted, to support the 
medical necessity of this request as an exception. Therefore, the requested left reverse shoulder joint 
replacement is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of reverse shoulder joint replacement surgery and associated procedures have not 
been met. Therefore, we decided that the Plan does not have to pre-approve reverse shoulder joint replacement 
surgery and associated procedures (76942, 64450, 54415 and 23472).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99223) provided on May 10, 2022. 
 
You asked the Plan to pay for the hospital care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 99223 is initial hospital care for the evaluation and 
management of a patient, requiring a comprehensive history, a comprehensive examination, and medical 
decision making of high complexity. 
 
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 hospital care. Our reviewer says that the records provided 
do not support the code billed. Our reviewer found the records do not support a comprehensive history or medical decision making of high complexity. 
 
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 hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for hospital care (99223) provided on May 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 4, 
2023, through February 5, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided 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 these services. 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 enrollee presented to the emergency department (ED) with a sudden onset of left flank 
pain radiating to the leg. The computed tomography (CT) scan showed a spigelian hernia on the left side but 
with only fat herniated and not the likely cause of the pain based on reports. After the workup in the ED and 
prior to admission, the enrollee reported no pain. He was admitted for pain control and a surgical consult for 
the hernia. However, the surgery was not likely related to the pain and the pain appeared to have resolved. His 
vital signs were stable. Based on the provided documentation prior to admission, it was not expected that the 
enrollee would have required hospital care that would have likely crossed 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from February 4, 2023, through February 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 1, 2023. 
 
You asked the Plan to pay for the services. 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 the place of service (POS) code to be used by the 
physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-
face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the office setting POS code. 
The records do not support that the services were provided in an office setting. Therefore, we decided that the 
Plan does not have to pay for the services provided on March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically 
ill or critically injured patient; first 30-74 minutes (99291) and each additional 30 minutes (99292) provided 
May 19, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Review of the records indicate 
surgery procedure 36581 has a global surgery value of 010 on the Centers for Medicare & Medicaid Services 
(CMS) National Physician Fee Schedule (NPFS) Relative Value (RVU) File. This is a minor procedure that has 
a global surgery period of 10 days. The initial Evaluation and Management (E&M) code, 99291 and 99292, is 
included when billed within the global surgery period of minor surgery procedure 36581 without an appropriate 
modifier. 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 the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) and each additional 30 minutes 
(99292) provided May 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 13, 2023, billed 
with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81306, 81328, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 13, 2023, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81306, 81328, and 
81335.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiography (93306) and injection, perflutren lipid 
microspheres, per ml (Q9957) provided March 21, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations.  
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Review of the file shows that for 
the procedure code submitted with this claim (93306) the facility has billed the following diagnoses code 
Z01.810 (for example, encounter for preprocedural cardiovascular examination). Medicares LCA A56781 
states that When reporting ICD-10 codes for pre-operative services, a secondary diagnosis for mitral valve 
prolapse is also required. Yet, the facility only provided secondary diagnosis codes of R93.1, J44.9, and 
R94.2. None of these diagnosis codes relate specifically to the mitral valve. As such, they do not satisfy the 
coding and billing requirements set forth in LCA A56781 as payable. The only valid revenue codes for Q9950-
Q9967 are 0254 and 0255. As Q9957 was billed with revenue code 0636, the line is not payable.  Therefore, 
we decided that the Plan does not have to pay for the echocardiography (93306) and injection, perflutren lipid 
microspheres, per ml (Q9957) provided March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you are requesting reimbursement for 
services rendered in good faith. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code B4185 billed for date of service April 3, 
2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed code is 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 B4185 is parenteral nutrition solution, not otherwise 
specified, 10 grams lipids. We find that 9 units of CPT code B4185 is not supported in the medical record. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code B4185 billed for date of service April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (EKG) (93010-59) and sedation 
(99152-SC) provided on January 13, 2023. 
 
You asked the Plan to pay for 93010-59 and 99152-SC. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says these codes cannot be verified as they have been 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 93010 is electrocardiogram, routine with at least 12 
leads; interpretation and report only. The CPT Code Manual definition of code 99152-SC is moderate sedation 
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; for patients 5 years of 
age or older for the first 15 minutes of intraservice time. 
 
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 93010-59 and 99152-SC. Our reviewer says that these codes do not meet criteria for payment. Our reviewer found the records do not include EKG with at least 12 leads; 
interpretation and report only. This procedure was not found in the medical record. Procedure report documents 
"Conscious sedation was performed as per protocol".  In this case, there is insufficient documentation, to 
confirm procedure criteria have been met, to include "requiring the presence of an independent trained observer 
to assist in the monitoring of the patient's level of consciousness and physiological status". 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 93010-59 and 99152-SC have not been met. Therefore, we decided that the Plan 
does not have to pay for an electrocardiogram (EKG) (93010-59) and sedation (99152-SC) provided on January 
13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM. Our physician reviewer 
found that you do not meet the clinical requirements, there is no record that you are on insulin or have a history 
of hypoglycemia. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G7 continuous glucose monitor (CGM).
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 February 22, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. 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 
February 22, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the basic radiation dosimetry calculation (77300-26) (18 
units) provided May 16, 2023. 
 
You asked the Plan to pay for procedure code 77300. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider has not documented any medically necessary reason for performing 
extra units in excess of the 10 allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 77300 is 10. The MAI value for this code is 3. You billed 18 units of this 
code; therefore, exceeding the MUE.  
 
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 77300. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found the provided records in this 
case do not document any medically necessary reason for performing extra units in excess of the 10 allowed.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 77300 have not been met. Therefore, we decided that the Plan does not have to 
pay for the basic radiation dosimetry calculation (77300-26) (18 units) provided May 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
April 27, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the billed 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. 
 
We find that CPT codes 96365 and 96366 are not supported in the medical record. The records show that the 
enrollee received outpatient intravenous insulin therapy. There is a more accurate code that describes the 
services provided. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365 and 
96366 billed for date of service April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81301 and 81194 billed for date of service 
February 27, 2023. 
 
You asked the Plan to pay for procedure codes 81301 and 81194. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says payment for codes 81301 and 
81194 is bundled into payment for code 81455. 
 
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 
81301 and 81194 are column II codes to column I code 81455. This claim has not been billed with an 
appropriate modifier to bypass the edit as the records do not support the use of the XU modifier. 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 81301 and 81194 billed for date of service February 27, 2023.