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

 
We decided that the Plan does not have to pay for procedure code 81455 billed for date of service December 
28, 2022. 
 
You asked the Plan to pay for procedure code 81455. You say that this test was necessary and was reported 
appropriately. The Plan denied your request. The Plan says the services provided would be better reported with 
a different CPT 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 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm or disorder, 51 or greater genes (e.g., ALK, BRAF, CDKN2A, CEBPA, 
DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MET, MLL, NOTCH1, NPM1, 
NRAS, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy 
number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis. 
 
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 procedure code 81455. Our reviewer says that this code is 
not supported. Our reviewer found that the laboratory report supports a solid tumor profile, which in this case a 
more specific code would be reported. Therefore, CPT 81455 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 procedure code 81455 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 81455 billed for date of service December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service May 17, 
2023.   
You asked the Plan to pay for procedure code 88341. 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 88341 is 13. The MAI value for this code is 3. You billed 14 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
March 15, 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 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded." 
 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 treated in the 
hospital by an infectious disease specialist on March 15, 2023. The documentation from that date describes the 
patient as presenting to the emergency department with back pain and a sacral wound with leukocytosis, but 
afebrile. Vitals were stable, and the examination was appropriate. The enrollee was to hold antibiotics until x-
rays results in and cultures direct care. The documentation did not support a high level of medical decision 
making nor did it include the duration of the encounter being 75+ minutes as required to justify CPT 99223.  
 
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 initial hospital care (procedure code 99223) rendered on March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83520 for date of service May 30, 2023. 
 
You asked the Plan to pay for procedure code 83520. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. 
 
We find that CPT code 83520 is not supported in the medical record. Specifically, this code is a not otherwise 
specified code. A complete description of the not otherwise specified code was not included. The order/ lab 
requisition/claim must include what laboratory test was ordered/requested in order to validate the not otherwise specified code billed. Based on this information, we decided that Medicare rules for coverage of procedure 
code 83520 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
83520 for date of service May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says that it is expected that the enrollee's medical records will reflect the need for the care 
provided. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 bed. Our reviewer says that the 
requested services are medically reasonable and necessary. Our physician reviewer found that you have 
weakness and difficulty with bed mobility. You require minimal assistance with bed mobility and is not 
independent with re-positioning. You have a history of a sacral abscess and osteomyelitis that required 
hospitalization. You are also currently requiring wound care for a Stage IV coccygeal pressure wound. You 
require re-positioning and has a pressure wound. Therefore, the requested semi-electric hospital 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 the bed have been met. Therefore, we decided that the Plan has to pre-approve a 
semi-electric hospital bed.  
 
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 pay for procedure code 63710-80-59 rendered on May 15, 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 procedure code 63710 is considered inclusive to CPT 63047. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
procedure details cite stem cell concentrate was placed on 25cc of ReBossis. This was mixed with the local 
iliac bone crest with this mixture packed within the InQu matrix which was packed and lateral gutters spanning 
L4 through S1 bilaterally. Nushield membrane was placed over the exposed dura as an adhesion barrier. This was performed with the noted laminectomy, facetectomy, and foraminotomy as a procedure to aid in healing. 

Therefore, the documentation does not support that CPT 63710: dural graft, spinal is a separate and distinct 
procedure from CPT 63047: laminectomy, facetectomy, and foraminotomy (unilateral or bilateral with 
decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single 
vertebral segment, lumbar. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 63710-80-59 rendered on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 15, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed date of 
services is incorrect. 
 
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 payment for CPT code 0315U is not supported in the medical record. Specifically, the claim 
should be billed with the date that the specimen was collected. In this case, the records show that the specimen 
was collected on November 18, 2022. Based on this information, we decided that Medicare rules for coverage 
of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on March 15, 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 the entire team of doctors advised you the absolute 
best course of action is for the enrollee to be admitted to the IRF. The Plan denied your request. The Plan says 
the IRF services requested do not meet the requirements for approval.  
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of erupted tooth (D7210) for tooth 
#6, #11, #14, #15, #22, #27, and #31. 
  
You asked the Plan to pre-approve the dental services. You say that the enrollee has gross decay on the 
remaining teeth and the requested surgical removal of erupted tooth is medically necessary. The Plan denied 
your request. The Plan says the denial of authorization for the requested services is correct, because the teeth 
show minimal decay and intact clinical crowns. An extraction (D7140) for tooth #6, #11, #14, #15, #22, #27, 
and #31 has been pre-approved. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the surgical removal of erupted tooth is not medically necessary. Our physician reviewer found that the 
teeth in the x-ray overlap each other, so it is difficult to see the sides of the teeth clearly. It is also difficult to 
see the bone level around most of the teeth. It is also difficult to see the anatomy of the roots of the teeth. The 
letter of appeal from the enrollee's physician states the teeth need to be extracted due to gross decay. The x-ray 
provided does not show the areas of decay clearly, and I am not able to determine whether there is gross decay 
on the teeth in question. Based on the information included in the review, the surgical removal of erupted tooth 
(D7210) for teeth #6, #11, #14, #15, #22, #27, and #31 are not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the surgical removal of erupted tooth (D7210) for tooth #6, #11, #14, #15, #22, #27, 
and #31.
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 the enrollee meets full medical and functional 
criteria to qualify for an inpatient acute rehabilitation stay. You say only this level of care can ensure maximal 
gains following the enrollee's discharge from their inpatient acute hospitalization. The Plan denied your 
request. The Plan says the request is denied as not medically necessary.  
 
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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee medical needs require a 
higher level of care to meet their current medical needs. You say that the enrollee is not stable to transfer to a 
skilled nursing facility. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary.  
 
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 enrollee is responding to their current treatment and only require short-term 
additional acute care services that can safely be provided at the current facility until they are more stable. 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left carpal tunnel release (64721). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the enrollee has end stage severe carpal 
tunnel syndrome with atrophy of the APB muscle and constant numbness in the fingers. You also say that 
splinting, physical therapy and cortisone will not work. The Plan denied your request. The Plan says there is no 
documentation of failure of non-invasive conservative treatment. 
 
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 the surgical procedure. Our reviewer 
says that the requested left carpal tunnel release is 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 documentation of any bracing, physical therapy, and injection for the left carpal tunnel. Moreover, there are no electrodiagnostic 
testing results provided to corroborate the pathology. 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 
to guidelines. Therefore, the requested left carpal tunnel release 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 the surgical procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve left carpal tunnel release (64721).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29540 billed for date of service June 1, 2023.  
 
You asked the Plan to pay for procedure code 29540. You say that you disagree with the Plan's denial. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 29540 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 29540 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 29540 billed for date of service June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 rendered on January 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 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 95937 is "Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method." 
 
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 underwent surgery and intraoperative monitoring services were provided during the procedure. One of the modalities assessed 
involved provision of train of four (TOF) testing. A claim was submitted for CPT 95937. However, there was 
no formal testing performed involving " Repetitive stimulation studies are used to identify and to differentiate 
disorders of the neuromuscular junction (NMJ)." In this case no disorders of the NMJ were being evaluated for. 
Rather, the testing done intraoperatively was to measure depth of anesthesia. Given that the code billed for did 
not reflect the services provided, this code would not be 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95937 rendered on January 11, 2023.