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

 
We decided that the Plan does not have to pay for code 99308-25 billed for date of service June 14, 2022. 
 
You asked the Plan to pay for code 99308-25. You say that the medical records support payment of this code. 
The Plan denied your request. The Plan says the use of the 25 modifier to allow for separate payment of code 
99308 for date of service June 14, 2022, is not supported by the medical record. The submitted documentation 
doesn't support a significant, separately identifiable evaluation and management service to support the use of 
the -25 modifier. 
 
The Plan follows Medicare rules. Medicare rules say that the 25 modifier is used for significant, separately 
identifiable evaluation and management services by the same physician on the same day of a procedure or other 
service. The documentation in the patient's medical record must support the use of this modifier. 
 
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 code 99308-25. Our reviewer says that the 
use of the 25 modifier to allow for separate payment of code 99308 is not supported in the medical record. Our 
physician reviewer found the medical record includes two evaluation and management procedures, signed by 
the same physician on June 14, 2022. The first one was at 12:20:29pm and the second one was at 
11:20:49am.  Each evaluation documents the same wording throughout, and therefore cannot be verified as a 
significant identifiable evaluation and management service.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99308-25 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99308-25 billed for date of service June 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 23, 2022, to 
May 28, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
claim was billed correctly. The Plan denied your request. The Plan says that secondary diagnosis code N17.0 is 
not supported. 
 
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 the secondary diagnosis of 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 of N17.0 (acute 
kidney failure with tubular necrosis) is not supported by the medical record. Our physician reviewer found the 
enrollee was treated for a urinary tract infection with sepsis.  Only one low blood pressure is noted, and the 
sepsis was repeatedly classified as without shock.  The enrollees renal function (BUN, Cr) remained consistent 
throughout the hospitalization, without evidence of severe or acute dysfunction, ischemia or necrosis. As such, 
the billing of N17.0 is not supported.  
 
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 May 23, 2022, to May 28, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx testing (0339U) provided January 9, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you are asking for this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the request for SelectMDx is not a 
covered benefit because this is not a test which has met the coverage criteria. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Liquid biopsy, such as SelectMDx are not considered a standard of care for the 
diagnosis of prostate cancer. The use is not supported by the National Comprehensive Cancer Network 
(NCCN) Guidelines or the medical literature. The service is not reasonable or 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the SelectMDx testing (0339U) provided January 9, 2023.
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 January 9, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. 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 January 
9, 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 this is the best next level of care for the 
enrollee to make a full recovery. The Plan denied your request. The Plan says the enrollee can safely receive 
the services they need in the current hospital setting. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where they are 
currently receiving 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: 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 medical needs. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient acute care and does not require transfer to a long-term acute care hospital. 
 
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 improving and should only require short-term 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. Completion of treatment at the current facility is recommended. 
 
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(s) 88341, 88342, 88360, and 88381 billed for 
date of service March 8, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. The Plan denied your 
request. The Plan says this code is included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service March 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 8, 2022, to 
March 9, 2022.  
You asked the Plan to pay for the home health services as billed. You say that you do not believe the admit date 
on the NOA and on the claim have to match. The Plan denied your request. The Plan says the claim has not 
been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 8, 2022, to 
March 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 15, 2022, 
to March 16, 2022.  
You asked the Plan to pay for the home health services as billed. You say that you do not believe that the NOA 
admit date and the claim admit date have to match. The Plan denied your request. The Plan says the claim has 
not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 15, 2022, to 
March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and lenses provided on November 10, 2022. 
 
You asked the Plan to pay for the frames and lenses. You say that you were not reimbursed for the eyewear. 
 The Plan denied your request. The Plan says the claim has been reprocessed and the Plan has paid up to the 
benefit amount. The second duplicate claim remains denied because the benefit has been exhausted with the 
partial overturn of the appeal. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to a $150 allowance. 
 
We looked at the file and the Plan's rules. Specifically, the Plan reprocessed the claim and paid the allowed 
$150 benefit amount. Based on this information, we decided that the Plan's rules for coverage of the frames and 
lenses have not been met. Therefore, we decided that the Plan does not have to pay for the frames and lenses 
provided on November 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection, diagnostic or therapeutic agent, paravertebral 
facet joint with image guidance, lumbar or sacral; single level (64493) and injection, diagnostic or therapeutic 
agent, paravertebral facet joint with image guidance, lumbar or sacral; second level (List separately in addition 
to code for primary procedure) (64494). 
 
You asked the Plan to pre-approve lumbar facet medial branch blocks. You say that the medical records 
provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the 
records do not support that the enrollee meets the Medicare criteria.  
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 lumbar facet Medial branch blocks. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the request is for lumbar facet medial branch blocks. However, there is no 
physical examination of the enrollee's lower back pain. Specifically, there is no range of motion assessment, 
reflexes, motor and sensory exam. Additionally, there were no facet loading tests are performed. Imaging 
results are also not included in the documents submitted. There is a lack documentation as required by the 
LCD. Therefore, at this time, the request is deemed not medically reasonable and 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 lumbar facet Medial branch blocks have not been met. Therefore, we decided 
that the Plan does not have to pre-approve injection, diagnostic or therapeutic agent, paravertebral facet joint 
with image guidance, lumbar or sacral; single level (64493) and injection, diagnostic or therapeutic agent, 
paravertebral facet joint with image guidance, lumbar or sacral; second level (List separately in addition to 
code for primary procedure) (64494).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 77080-26 billed for date of service September 12, 2022. 
 
You asked the Plan to pay for code 77080-26. You say that this claim was billed correctly. The Plan denied 
your request. The Plan says procedure code 77080 is not supported when billed with diagnosis Z13.820. 
 
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 77080-26 is  Dual-energy X-ray absorptiometry (DXA), 
bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine). 
 
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 code 77080-26. Our reviewer says that code 77080-26 is not 
supported by the medical record. Our reviewer found the medical records and billing records indicate diagnosis 
code Z13.820 - encounter for screening for osteoporosis- was the only diagnosis code billed with CPT code 77080 26.  Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, 
hips, pelvis, spine) is not reimbursable when billed with diagnosis Z13.820 only and there is not a valid 
diagnosis to indicate the reason for testing. Therefore, this service is not eligible for reimbursement. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 77080-26 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 77080-26 billed for date of service September 12, 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 August 27, 
2022, to August 29, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was critical care, and an inpatient 
admission was medically necessary. The Plan denied your request. The Plan says that the inpatient admission 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee was stable and other major acute conditions were ruled out. There is 
insufficient support from the documentation provided to suggest that the enrollee would require hospital 
services that would likely cross two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from August 27, 2022, to August 29, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure codes 99232 and 99233) 
rendered from April 15, 2022, to April 24, 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 99232 and 99233 remain 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 the denied codes is: 
 
CPT 99232: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused 
examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to 
therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the 
patient's hospital floor or unit. 
 
CPT 99233: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new 
problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
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 documentation 
does not support the CPT code 99232.  The documentation available for review does not support that 2 of the 3 
key components were present for the evaluation and management. The records also do not support CPT 99233. 
The documentation available for review does not support the enrollee developed a significant complication or 
that medical decision making of high complexity was needed. 
 
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 subsequent hospital care (procedure codes 99232 and 99233) rendered from April 15, 2022, to 
April 24, 2022.