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

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent (64635, 64636). 
 
You asked the Plan to pre-approve destruction by neurolytic agent. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the procedure is not 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 destruction by neurolytic agent. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no 
documentation indicating that the enrollee had two medically reasonable and necessary diagnostic facet joint 
procedures with each one providing a consistent minimum of 80% relief of primary pain with the duration of 
relief being consistent with the agent used. The review has determined that the enrollee does not meet the LCD 
criteria for destruction by neurolytic agent. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent have not been met. Therefore, we decided that 
the Plan does not have to pre-approve destruction by neurolytic agent (64635, 64636).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an EsophyX procedure and related computed tomography (CT) 
services. 
 
You asked the Plan to pre-approve an EsophyX procedure and related CT services. You say that the records 
provided support that the services in dispute are medically necessary.  The Plan denied your request. The Plan 
says that procedures other than transoral incisionless fundoplication (TIF) are non-covered due to the fact that 
current peer-reviewed literature does not support the long-term efficacy and long-term safety of the services. 
The Plan says that this procedure is not proven effective.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an EsophyX procedure and related CT 
services. Our reviewer says that an EsophyX procedure and related CT services are considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has gastroesophageal reflux 
disease (GERD) refractory to conservative therapy. EsophyX is approved by the Food and Drug Administration 
(FDA) and was recently added to national clinical guidelines. This procedure and the related CT services were 
medically appropriate in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EsophyX procedure and related CT services have been met. Therefore, we 
decided that the Plan has to pre-approve an EsophyX procedure and related computed tomography (CT) 
services.  
 
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 pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving the 
appropriate inpatient acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be responding to the current treatment but still requires 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. The enrollee does not require services at the LTACH that are not already available at 
the current facility.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October 
26, 2022, to November 30, 2022. 
 
You asked the Plan to pay for SNF care. You say that this is not a duplicate claim. The Plan denied your 
request. The Plan says this claim is duplicate off of another claim which paid for dates of service October 19, 
2022, to October 31, 2022. 
 
The Plan follows Medicare rules. Medicare rules state that SNF claims must be billed with certain data 
elements. 
 
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 SNF care. Our reviewer says that this claim 
does not meet criteria for payment. Our physician reviewer found the records are inadequate to clarify that this 
claim is not duplicating off of another claim with dates of service October 19, 2022, to October 31, 2022 which 
was paid. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from October 26, 2022, to November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient intravenous insulin treatment (OIVIT) 
provided on February 27, 2023. 
 
You asked the Plan to pay for the OIVIT services. You say that this should be covered due to medical 
necessity. The Plan denied your request. The Plan says this service is not covered and was not billed correctly.  
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is nationally non-covered.  Therefore, we 
decided that the Plan does not have to pay for the outpatient intravenous insulin treatment (OIVIT) provided on 
February 27, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure codes 80053, 80061, 84443, 
82607, and 85025. We decided that the Plan does not have to pay for the services described by procedure code 
84436.  
 
You asked the Plan to pay for procedure code 84436 billed for date of service March 27, 2023.. You say that 
you are an independent lab that works with physician's offices and hospitals. The Plan says that there are no 
modifiers allowed with this code pair. 
 
We decided that the Plan has to pay for the services described by procedure codes 80053, 80061, 84443, 
82607, and 85025.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure codes 80053, 80061, 84443, 82607, 
and 85025 billed for date of service March 27, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 84436. 
 
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 84436 is a column II code to column I code 84439 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services described 
by procedure code 84436 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99214 and 
the radiology services coded as 74230, 74240, 71045, and 72040 performed on January 31, 2023 
 
You asked the Plan to pay for the services performed on January 31, 2023. You say that the services performed 
on January 31, 2023, should be covered because they are supported in the documentation. The Plan denied your 
request. The Plan says codes 74230 and 74240 are not covered benefits because they are listed in the 
Exclusions from Coverage as Portable X-Ray Services section of the Medicare Benefit Policy Manual. Codes 
99214, 71045, and 72040 are not covered because they were billed with an inappropriate POS. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology services performed in the mobile 
setting are not eligible for reimbursement if they are listed in the Exclusions from Coverage as Portable X-Ray 
Services section of the Medicare Benefit Policy Manual. Medicare rules also state that claims must be billed 
with the appropriate POS.  
 
We looked at the file and Medicare rules. Documentation provided shows codes 74240 and 72430 were 
performed in a mobile unit setting with the use of fluoroscopy. Therefore, they are not covered and are 
excluded under the portable x-ray provision. Codes 99214, 71045, and 72040 were billed with POS 11, 
indicating an office setting. However, documentation shows these services were performed in a mobile setting. 
There is no evidence the services were provided in an office setting. Based on this information, we decided that 
Medicare rules for coverage of services performed on January 31, 2023, have not been met. Therefore, we 
decided that the Plan does not have to pay for the evaluation and management services coded as 99214 and the 
radiology services coded as 74230, 74240, 71045, and 72040 performed on January 31, 2023
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4222 provided from February 24, 2023, to 
March 2, 2023. 
 
You asked the Plan to pay for procedure code A4222. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered 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. 
 
Medicare says that unconditionally packaged services are identified in the OPPS Addendum B with status 
indicator of N and these services are not paid separately since payment is included in the APC. Code A4222 is 
identified with a status indicator of N. Therefore, we decided that the Plan does not have to pay for procedure 
code A4222 provided from February 24, 2023, to March 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an enhanced display kit and a midline mount for the 
approved power wheelchair. 
 
You asked the Plan to pre-approve an enhanced display kit and a midline mount. You say that the requested 
enhanced display kit and midline mount is medically necessary.  The Plan denied your request. The Plan says 
the requested enhanced display kit and midline mount 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 an enhanced display kit and a midline 
mount. Our reviewer says that the requested enhanced display kit and midline mount is not medically 
necessary.  Our physician reviewer found the documentation does not indicate that the requested enhanced 
display kit and midline mount serve a medical purpose and are therefore not medically 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 an enhanced display kit and a midline mount have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an enhanced display kit and a midline mount for the 
approved power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided April 2, 2023. 
 
You asked the Plan to pay for lab tests. You say that this coding is approved by Medicare. The Plan denied 
your request. The Plan says these codes are components of a multi-component code and it would be more 
appropriate to bill a different code. 
 
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 87481 is candida species, amplified probe technique. 
 
The CPT Code Manual definition of code 87491 is chlamydia trachomatis, amplified probe technique. 
 
The CPT Code Manual definition of code 87500 is vancomycin resistance (eg, enterococcus species vaA, van 
B), amplified probe technique.  
The CPT Code Manual definition of code 87563 is streptococcus, group B, amplified probe technique. 
 
The CPT Code Manual definition of code 87640 is staphylococcus aureus, amplified probe technique. 
 
The CPT Code Manual definition of code 87641 is staphylococcus aureus, methicillin resistant, amplified 
probe technique, 
 
The CPT Code Manual definition of code 87653 is streptococcus, group B, amplified probe technique. 
 
The CPT Code Manual definition of code 87798 is infectious agent detection by nucleic acid (DNA or RNA), 
not otherwise specified, amplified probe technique, per organism probed. 
 
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 lab tests. Our reviewer says that these codes do not meet 
criteria for payment. 
 
For codes 84781, 87491, 87563, 87640, 87641, and 87653 our reviewer found that the medical record includes 
a signed physician order; however, laboratory tests ordered were not documented on order. Healthcare provider 
reported multiple infectious organisms, in which this procedure would be included. Laboratory report does not 
support procedure code and modifier 59 distinct procedural service, as rationale cannot be verified. 
 
For code 87500 our reviewer found that the medical record includes a signed physician order, however 
laboratory tests ordered was not documented on order. Laboratory report does not include documentation of 
this procedure, was unable to cite report, as this procedure was not found. 
 
For code 87798 our reviewer found that medical record includes a signed physician order; however, laboratory 
tests ordered was not documented on order. Also, procedure code is a "not otherwise specified" code, 
documentation does not include documentation of specific tests billed with this procedure code and cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided April 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service April 7, 
2023. 
 You asked the Plan to pay for procedure code 93042. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 12013. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93042 
is a column II code to column I code 12013. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042 billed for date of service April 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 1 unit of code 77022, defined as magnetic resonance imaging 
guidance for, and monitoring of, parenchymal tissue ablation, and 98 units of code Q9966-JW, defined as 
discarded units of low osmolar contrast material, 200-299 milligram (mg)/milliliter(ml) iodine concentration, 
per ml.  
 
You asked the Plan to pay for codes 77022 (1 unit) and Q9966-JW (98 units). You say that 77022 and Q9966-
JW (98 units) should be covered because they are supported in the documentation. The Plan denied your 
request. The Plan says 77022 is not supported because records do not show magnetic resonance imaging 
guidance for, and monitoring of, parenchymal tissue ablation; was performed. Q99666-JW is not supported 
because the units billed do not correspond with the smallest dose (vial) available for purchase that could 
provide the appropriate dose for this beneficiary. 
 
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly. The rules also say that for Medicare to cover the discarded amount of a drug, the units billed should 
correspond with the smallest vial available for purchase that can provide the necessary dose. The rules also say 
that for Medicare to cover the discarded amount of a drug, the units billed should correspond with the smallest 
vial available for purchase that can provide the necessary dose.  
 
We looked at the file and Medicare rules. While 77022 was billed, the record shows a procedure note for knee 
joint arthrography with injection and fluoroscopic guidance rather than magnetic resonance imaging guidance 
for, and monitoring of, parenchymal tissue ablation. Therefore, 77022 is unsupported.  
 
Q9966-JW was billed with National Drug Code (NDC) 00407-1412-33, containing 100 billable units but 
records show that only 2 units of the drug were used. This resulted in 98 units being discarded. We were able to 
confirm that under NDC 00407-1412-10, this drug is available for purchase in a vial with 10 billable units, 
which would have resulted in the least amount of wastage, as required for coverage. Based on this information, 
we decided that Medicare rules for coverage of codes 77022 (1 unit) and Q9966-JW (98 units) have not been 
met. Therefore, we decided that the Plan does not have to pay for 1 unit of code 77022, defined as magnetic 
resonance imaging guidance for, and monitoring of, parenchymal tissue ablation, and 98 units of code Q9966-
JW, defined as discarded units of low osmolar contrast material, 200-299 milligram (mg)/milliliter(ml) iodine 
concentration, per ml.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 90 units of procedure code 01402 rendered on January 30, 
2023. 
 
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 number of units 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 01402 is "Anesthesia for open or surgical arthroscopic 
procedures on knee joint; total knee arthroplasty." 
 
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 in this case, the anesthesia time is 
12:59 - 14:29, which is 90 minutes/15 minutes = 6 units for CPT 01402. The Base Units for CPT 01402 = 7 
base units. According to the formula above: Base Unit Value + Time Units = 7 units + 6 units = 13 total units 
(which is then multiplied by the conversion factor for reimbursement). The submitted medical records do noy 
support the 90 units billed for the intraoperative anesthesia services (CPT 01402) provided.  The correct 
number of units to be billed for this case (12:59-14:29) should be 13 units. The Base Units for the adductor 
canal block for acute post-operative pain is billed separately. The time for placement is mot added or included 
in the total intraoperative anesthesia time for CPT 01402). This is billed on a separate line. 
 
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 90 units of procedure code 01402 rendered on January 30, 2023.