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

 
We decided that the Plan does not have to pay for the lab testing billed for date of service January 25, 2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the diagnosis codes 
billed. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported 
together. 
 
The Plan follows Medicare rules. The rules say that certain diagnosis codes have an Excludes1 note which lists 
other diagnosis codes with which they cannot be reported.  In this case, we have confirmed that diagnosis code group C44.- has an Excludes1 note in relation to diagnosis 
code group C43.-. This means that diagnosis codes C43.59 and C44.619 cannot be reported together. Based on 
this information, we decided that the Medicare billing rules have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing billed for date of service January 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service January 2, 
2023.  
 
You asked the Plan to pay for procedure code 76942. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that 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 76942 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 76942 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76942 billed for date of service January 2, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service May 25, 
2023, to June 23, 2023. 
 
You asked the Plan to pay for the billed services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the rules for payment have not been met. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 9, 2023. The services in question were provided before 
the end of that month. A separate claim should be billed for the services provided after the months end where 
hospice was revoked. Based on this information, we decided that the Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health care billed for dates of 
service May 25, 2023, to June 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation billed for date of service 
February 17, 2023. 
 
You asked the Plan to pay for the billed services. You say that the services were coded appropriately. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that certain diagnosis codes have an Excludes1 note which lists 
other diagnosis codes with which they cannot be reported.  In this case, we have confirmed that R55 has an Excludes1 note in relation to R40.2-. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ambulance transportation billed for date of service February 17, 2023.
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 enrollee needs this care which offers 
a wide range of comprehensive services. The Plan denied your request. The Plan says the enrollee does not 
require services at the LTACH that are not already available at the current facility. 
 
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 that the records do not support the need to transfer to an LTACH. Continued care in 
the short-term acute hospital is appropriate until the enrollee is stable to transfer to a lower level of care. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 1, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 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 code 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service March 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99214) 
rendered on April 17, 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 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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
 
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 from this date 
describes the enrollee as presenting with left knee pain, having failed NSAIDs (nonsteroidal anti-inflammatory 
drugs). The enrollee was treated with a steroid injection at the same visit, which was tolerated. CPT 20610 was 
submitted alongside CPT 99214. However, CPT 99214 would be included within CPT 20610, making the 
request for payment for CPT 99214 redundant. The provided documentation does not sufficiently support the 
code 99214 was a significant and separately identifiable evaluation and management service from 20610. 
 
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 evaluation and management services (procedure code 99214) rendered on April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96367, 96375, 96413, 96415, 96416, 96417, 
J0640, J9190, J9206, J9263 rendered on April 3, 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 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 the denied codes is: 
 
CPT 96367: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure) 
 
CPT 96375: 
 
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential 
intravenous push of a new substance/drug (List separately in addition to code for primary procedure) 
 
CPT 96413: 
 
Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug 
 
CPT 96415: 
 
Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition 
to code for primary procedure) 
 
CPT 96416: 
 
Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion 
(more than 8 hours), requiring use of a portable or implantable pump 
 
CPT 96417: 
 
Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different 
substance/drug), up to 1 hour (List separately in addition to code for primary procedure) 
 
Healthcare Common Procedure Coding System (HCPCS) J0640: 
 
Injection, leucovorin calcium, per 50 mg 
 
HCPCS J9190: 
 
Injection, fluorouracil, 500 mg 
 
HCPCS J9206: 
 
Injection, irinotecan, 20 mg 
 
HCPCS J9263: 
 
Injection, oxaliplatin, 0.5 mg 
 
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 96367, 96375, 96417, 96416, 96413 and 96415. The notes show that chemo therapy and injections 
were held. 
 
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 procedure codes 96367, 96375, 96413, 96415, 96416, 96417, J0640, J9190, J9206, J9263 
rendered on April 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on December 16, 2021. 
 
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 services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that home health claims are paid based on HIPPS codes. 
 
We looked at the file and Medicare rules. The file shows that the records do not support the billed HIPPS 
codes. The Plan adjusted payment for the claim based on the records. Therefore, we decided that the Plan does 
not have to pay for the home health services rendered on December 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes J7999, & 95990 provided on February 2, 
2023. 
 
You asked the Plan to pay for procedure codes J7999, & 95990. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes J7999, & 95990 are not supported in the medical record. Specifically, the claim was 
billed with place of service 12 (home setting) however the records do not substantiate that this service was 
performed in the home setting. Based on this information, we decided that Medicare rules for coverage of 
procedure codes J7999, & 95990 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes J7999, & 95990 provided on February 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 23600 rendered on March 22, 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 Current Procedural Terminology (CPT) code 23600-54-LT 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 23600 is "Closed treatment of proximal humeral (surgical 
or anatomical neck) fracture; without manipulation." 
 
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 was being treated for 
a nondisplaced fracture of the greater tuberosity of the left humerus. The enrollee presented to the emergency department after a mechanical ground-level fall. The enrollee has left shoulder pain. The exam is notable for 
diffuse left shoulder pain. The extremity continued to be neurovascular. The treatment plan included 
medications for breakthrough pain as well as follow-up with orthopedics for continued evaluation and 
management. However, detailed documentation is not evident that treatment (outside of x-rays and an initial 
emergency room examination) was performed for the left upper extremity. Therefore, the documentation does 
not support that CPT 23600: closed treatment of proximal humeral (surgical or anatomical neck) fracture; 
without manipulation was rendered in this case.  
 
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 procedure code 23600 rendered on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve membrane wrap (Q4205). 
 
You asked the Plan to pre-approve membrane wrap. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 membrane wrap. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found because the wound is decreasing in size, it is not clear that the membrane wrap is 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 membrane wrap have not been met. Therefore, we decided that the Plan does 
not have to pre-approve membrane wrap (Q4205).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (procedure code 00832) rendered on 
April 11, 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 Current Procedural Terminology (CPT) code 00832 AA (177 units) 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 00832 is "Anesthesia for hernia repairs in lower 
abdomen; ventral and incisional hernias." 
 
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 if the hernia is above the 
umbilicus, it is considered upper abdominal, and anesthesia CPT codes 00750, 00752, or 00790 are 
appropriate. If it is below the umbilicus, it is considered lower abdominal, and anesthesia codes 00830, 00832, 
00834, 00836, or 00840 are appropriate. CPT code 00790 (Anesthesia for intraperitoneal procedures in upper 
abdomen including laparoscopy) would be the best billing code for the anesthesia services rendered for the 
surgical procedures performed. The documentation does not support that CPT 00832 was rendered in this 
case. The submitted medical records also do not support the 177 units billed for the intraoperative anesthesia 
services provided. The correct number of units to be billed for this case should be based on CPT code 00790 
for a total of 20.5 units. 
 
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 anesthesia services (procedure code 00832) rendered on April 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this care to regain strength. The Plan 
denied your request. The Plan says your medical condition does not require IRF services, and care can be 
provided in another setting.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your medical, rehabilitation, and nursing needs do not require IRF 
care with an interdisciplinary approach to rehabilitative care. Your rehabilitation needs can be safely provided 
in an alternate setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on April 6, 2023. 
 
You asked the Plan to pay for ambulance services. You say that you were not told you would be charged for 
this. The Plan denied your request. The Plan says this was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says that 
the ambulance services at issue were not medically necessary. Our physician reviewer found the documentation 
does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other 
type of vehicle) were contraindicated or that you needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully equipped ambulance can provide for safe transport. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does 
not have to pay for ambulance services provided on April 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on April 26, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that you billed with covered diagnoses. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that J42 has an Excludes1 note in relation to J44.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for 
oxygen equipment provided on April 26, 2023.