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

 
We decided that the Plan has to pay for procedure code 14301. We decided that the Plan does not have to pay 
for procedure code 99204-25.  
 
You asked the Plan to pay for procedure codes 99204-25 and 14301 billed for date of service August 11, 2022. 
You say that services were provided in good faith. The Plan says that an inappropriate modifier was billed. 
 
We decided that the Plan has to pay for procedure code 14301.  
 
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. 
 
In this case, the Plan has not explained why procedure code 14301 is not payable. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for procedure code 14301 billed for date of service 
August 11, 2022.  
 
We also decided that the Plan does not have to pay for procedure code 99204-25. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that modifier -25 is used in conjunction with minor procedures. However, procedure code 14301 is a 
major surgical procedure. 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 procedure code 99204-25 billed for date 
of service August 11, 2022. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64447 billed for date of service December 
12, 2022.  
 
You asked the Plan to pay for procedure code 64447. 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 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 64447 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 64447 have not been met.  Therefore, we decided that the 
Plan does not have to pay for procedure code 64447 billed for date of service December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron Tab 4mg. 
 
You asked the Plan to pre-approve the medication. You say that the drug is being initiated within 2 hours of the 
administration of cancer chemotherapy and continued for a period not to exceed 48 hours from that time. The 
Plan denied your request. The Plan says the medication is not provided from a physician supply or incident to a 
physician service. The enrollee has a MA plan only and this request is for an outpatient drug therapy, therefore 
this is a plan benefit exclusion. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron Tab 4mg.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 26, 2022, to 
January 24, 2023. 
 You asked the Plan to pay for the home health services. You say that you had to resend the NOA to correct the 
admission date. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is November 26, 2022. A valid NOA was not received by the Plan until 
January 24, 2023. As more than 30 days passed between the timely filing date and the valid NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health 
services provided from December 26, 2022, to January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 You asked the Plan to pre-approve epidural steroid injection. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the enrollee does not experience pain severe enough to impair 
functional activities. 
 
The Plan follows Medicare rules. Medicare rules state that epidural steroid injections are only covered if certain 
criteria are met. 
 
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 epidural steroid injection. Our reviewer 
says that the enrollee does not meet criteria for this procedure. Our physician reviewer found the enrollee does 
not have radicular signs or imaging that support spinal or foraminal stenosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 87481 billed for date of service May 17, 2022. 
 
You asked the Plan to pay for procedure code 87481. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says that this service is not supported in the medical record. 
 
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 infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe 
technique. 
 
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 87481. Our reviewer says that this code is 
supported in the medical record. Our reviewer found the medical records do support the use of 87481 being 
billed as the lab result for Candida species was detected and preformed. 
 
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 87481 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87481 billed for date of service May 17, 2022.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 3, 2022, 
to December 2, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. 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 November 3, 2022, to 
December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital evaluation and management (EM) services 
provided on December 15, 2022.  
 
You asked the Plan to pay for the EM services. You say that the services should be paid due to medical 
necessity. The Plan denied your request. The Plan says the two of the diagnosis codes billed cannot be reported 
together.  
 The Plan must follow Medicare rules. Medicare rules say that ICD-10-CM coding guidelines indicate that if a 
diagnosis code has an Excludes1 note, it should not be reported with the excluded other diagnosis code.  
 
We looked at the file and Medicare rules. This claim was billed with diagnosis codes J44.1 and J47.9. J44 has 
an Excludes1 note for codes in the J47 range. This means that the two codes should not be reported together. 
Based on this information, we decided that Medicare rules for coverage of the EM services have not been met. 
Therefore, we decided that the Plan does not have to pay for the hospital evaluation and management (EM) 
services provided on December 15, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 for date of service December 2, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the service billed is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and 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 presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. 
 
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 99285. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee presented to the emergency 
department with a two-week history of severe back pain after twisting her back. The examination was notable 
for tenderness in the lower lumbar spine area, pain with movement, and limited range of motion due to pain. X-
ray of the lumbar spine was negative. The final diagnoses were acute bilateral low back pain without sciatica, 
and lumbar strain, initial encounter. The enrollee was given a prescription for Norco and Flexeril and was 
advised to follow-up with the enrollee's primary care physician. The documentation does not support medical 
decision making of high complexity. Therefore, code 99285 is not supported. 
 
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 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 for date of service December 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on August 17, 
2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on August 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography (PSG) (95811). 
 
You asked the Plan to pre-approve a PSG. You say that you would like this request to be reconsidered. The 
Plan denied your request. The Plan says this service 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 a PSG. Our reviewer says that an 
attended, split night polysomnogram with positive airway pressure (PAP) titration is not medically necessary. 
Our physician reviewer found this enrollee has symptoms consistent with obstructive sleep apnea, and a home 
sleep test on February 6, 2023, confirmed mild obstructive sleep apnea, with an apnea-hypopnea index of 6.7.  
Thus, the diagnostic portion of the ordered sleep study is not necessary because it would duplicate the home 
sleep test. Our reviewer found that it would be reasonable to start the enrollee on auto titrating continuous 
positive airway pressure (CPAP). Our physician reviewer also found that an attended PAP titration would be 
necessary only if the enrollee's sleep disordered breathing is not adequately treated with the auto titrating 
CPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PSG have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a polysomnography (PSG) (95811).
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance amount by $1.24 for the nasal application device, 
positive airway pressure filter, and tubing with heated element. We decided that the Plan does not have to fully 
waive the coinsurance for the nasal application device, positive airway pressure filter, and tubing with heated 
element.  
 
You asked the Plan to waive the coinsurance for the nasal application device (A7034), positive airway pressure 
filter (A7038), and tubing with heated element (A4604) provided on July 19, 2022. You say that you never paid 
a copay before. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the coinsurance amount by $1.24 for the nasal application device, 
positive airway pressure filter, and tubing with heated element.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance).  
 
Your contract with the Plan clearly says that you must pay an 18% coinsurance for the nasal application device, 
positive airway pressure filter, and tubing with heated element. The record shows that you were overcharged 
for these services. 
 
Item 
Allowed 
Amount 
Cost-Share Per 
Contract 
Amount You Were 
Asked to Pay 
Your Cost-Share 
Responsibility 
Positive Airway 
Pressure Filter 
(A7038) 
$11.63 18% coinsurance $2.36 $2.09 
Nasal Application 
Device (A7034) 
$52.50 18% coinsurance $9.61 $9.45 
Tubing with Heated 
Element (A4604) 
$34.89 18% coinsurance $7.09 $6.28 
Total   $19.06 $17.82 
 
You were charged a total of $19.06, but the math shows you should only have been charged a total of $17.82 
for these services. Therefore, we decided that the Plan has to reduce the coinsurance amount by $1.24 for the 
nasal application device, positive airway pressure filter, and tubing with heated element.  
 
We also decided that the Plan does not have to fully waive the coinsurance for the nasal application 
device, positive airway pressure filter, and tubing with heated element. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay an 18% 
coinsurance for the nasal application device, positive airway pressure filter, and tubing with heated element. 
Therefore, we decided that the Plan does not have to fully waive the coinsurance for the nasal application 
device, positive airway pressure filter, and tubing with heated element. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377, and 88381 
billed for date of service September 23, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, 88377, 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, 
88377, 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, 88377, and 88381. Based on this information, we decided that Medicare rules for 
coverage of procedure code 88341, 88342, 88360, 88377, and 88381 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377, and 88381 billed for date 
of service September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three additional units of procedure code 99458 rendered on 
October 27, 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 there is no specific rationale as to why additional units were needed to be provided. 
 
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 99458 is "Remote physiologic monitoring treatment 
management services, clinical staff/physician/other qualified health care professional time in a calendar month 
requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes 
(List separately in addition to code for primary procedure)." 
 
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 records do not clearly indicate 
why the three additional units of CPT 99458 were medically necessary for this enrollee. 
 
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 three additional units of procedure code 99458 rendered on October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerves, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635). 
 
You asked the Plan to pre-approve sacroiliac joint (SIJ) denervation. You say that the enrollee needs facet 
denervation. The enrollee had SIJ block with significant relief of symptoms. She would like to avoid repeat 
steroids if possible. The provider did the blocks to see if she would be a good candidate for the RFA and they 
prove that she is. Medical records attached to support medical necessity. The Plan denied your request. The 
Plan says the requested service is not considered reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of sacroiliac joint (SIJ) denervation have not been met. Specifically, SIJ Denervation is not 
considered reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve 
destruction by neurolytic agent, paravertebral facet joint nerves, with imaging guidance (fluoroscopy or CT); 
lumbar or sacral, single facet joint (64635).