Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services performed on January 6, 
2023. 
 
You asked the Plan to pay for the outpatient hospital services. You say that the outpatient hospital services 
should be paid as billed because they were billed correctly, and device codes are present on the claim. The Plan 
denied your request. The Plan says the outpatient hospital services are denied due to I/OCE edit 92, meaning a 
device intensive procedure was reported without a device code. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service July 1, 
2007, and after, the non-Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be 
integrated into the OPPS OCE. The rules also say that the submission of a device-intensive procedure also 
requires that a code for a device be submitted on the same claim/day. 
 
We looked at the file and Medicare rules. In this case, code 28291 was billed. 28291 is listed as a device-
intensive procedure on the I/OCE Quarterly Data Release Files website. We confirmed that an I/OCE edit 92 
indicates a device-intensive procedure was reported without a device code. We confirmed that no device code 
was billed on the claim with 28291. Based on this information, we decided that Medicare rules for coverage of 
the outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for 
the outpatient hospital services performed on January 6, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (procedure code 87506) rendered on December 20, 
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 that Current Procedural Terminology (CPT) code 87506 (1 Unit) 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 87506 is "Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, 
Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse 
transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 
targets." 
 
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 supported by the medical records. Our reviewer found that an enrollee with diarrhea was referred 
for diarrhea pathogen and genotypic resistance panel. The documentation does support that CPT 87506 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 been met. Therefore, we decided that the Plan has to pay for 
laboratory services (procedure code 87506) rendered on December 20, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on September 18, 2022. 
 
You asked the Plan to pay for ambulance services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
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 
transportation via ambulance from the hospital to the residential facility was not medically necessary. Our 
physician reviewer found you not bedbound, as evidenced by your ability to walk. You did not require the 
expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a 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 September 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82306, 82533, 82607, 82627, 82670, 82746, 
83003, 83520, 83540, 83735, 83970, 84144, 84146, 84270, 84305, 84403, 84439, 84481) provided February 
28, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 82306, 82533, 82607, 82627, 82670, 82746, 83003, 83520, 83540, 83735, 83970, 
84144, 84146, 84270, 84305, 84403, 84439 and 84481 are not supported in the medical record. Specifically, 
the lab order does not specify what tests are to be performed. 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 lab services (82306, 82533, 82607, 82627, 82670, 82746, 83003, 83520, 83540, 83735, 83970, 
84144, 84146, 84270, 84305, 84403, 84439, 84481) provided February 28, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you believe the enrollee's best chance for 
a quicker recovery and more favorable outcome will be with admission to the LTACH. The Plan denied your 
request. The Plan says that that the records do not show that it is medically necessary to be in an LTACH in 
place of an 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 considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee meets criteria for transfer to an LTACH at this time. It is noted that the 
enrollee is on high flow nasal cannula at 60L and 60% FIO2 but she appears stable and tolerating current 
settings per progress reports. Imaging appears stable, no progression in lung findings. The enrollee has 
complex medical needs that further complicate their current condition. Due to the enrollee's past and present 
problems, they require daily physician rounding and a multidisciplinary team of highly skilled nurses, 
respiratory therapists, and a physical/occupation therapist. The transfer to an LTACH is therefore appropriate. 
 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve LTACH services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on December 27, 2022, to 
December 30, 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 the 
billed DRG is supported. The Plan denied your request. The Plan says that the billed DRG 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 A41.9 - Sepsis, unspecified organism. 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 physician reviewer found the enrollee meets criteria for systemic inflammatory response syndrome and 
with lung source; therefore, A41.9 is justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on December 27, 2022, to December 30, 2022, at the Diagnosis Related Group 
(DRG) originally billed.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need this level of care.  The Plan denied your 
request. The Plan says the medical records do not show a need for SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve selective catheter placement, arterial system; initial 
second order abdominal, pelvic, or lower extremity artery branch, within a vascular family (36246) and 
selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower 
extremity artery branch, within a vascular family (36247). 
 
You asked the Plan to pre-approve selective catheter placement. You say that treatment is medically necessary, 
and you have submitted records for review. The Plan denied your request. The Plan says the request is not 
medically necessary because there is little evidence in the medical literature to suggest that this is an 
appropriate product to be used for the enrollee's knee arthritis. 
 
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 selective catheter placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based on the medical records provided, there is no documentation that the 
genicular artery embolization at issue in this case meets all Medicare criteria for medically reasonable and 
necessary and safe and effective for the enrollee. Provided medical records and review of the current peer-
reviewed medical literature do not document that genicular artery embolization has been shown in controlled 
studies in a Centers for Medicare & Medicaid Services (CMS) approved journal to result in long term health 
benefits in enrollees with pain related to osteoarthritis of the knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of selective catheter placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve selective catheter placement, arterial system; initial second order abdominal, 
pelvic, or lower extremity artery branch, within a vascular family (36246) and selective catheter placement, 
arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within 
a vascular family (36247).
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99223 and 99232. We decided that the Plan does not have to pay for 
99233 and 99238.  
 
You asked the Plan to pay for hospital services (procedure codes 99223, 99232, 99233, and 99238) rendered 
from January 4, 2023, to January 23, 2023.. You say that this should be paid for. The Plan says that the records 
do not support the services billed.  
We decided that the Plan has to pay for 99223 and 99232.  
 
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 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 for CPT 99223 and CPT 99232. Our reviewer says that 
the records support that these codes were performed in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
99223 and 99232.  
 
We also decided that the Plan does not have to pay for 99233 and 99238. 
 
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 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 for CPT 99233 and CPT 99238. Our reviewer says that 
the records do not support the high level of decision making for CPT 99233, or the discharge notes for CPT 
99238. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99233 and 99238 have not been met. Therefore, we decided that the Plan does 
not have to pay for 99233 and 99238. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from March 3, 2023, through March 6, 
2023. 
 You asked the Plan to pay for the SNF care. You say that the SNF services the enrollee received were 
necessary and coverable. The Plan denied your request. The Plan says the enrollee did not require SNF 
services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the enrollee no longer qualified for SNF 
coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented 
skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs could have been provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from March 3, 2023, through March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87506 billed for date of service April 15, 
2022. 
 
You asked the Plan to pay for procedure code 87506. You say that this testing was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this code does not accurately report the services 
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 87506 is infectious agent detection by nucleic acid (DNA 
or RNA); gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, 
Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, 
multiple types or subtypes, 6-11 targets. 
 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 87506. Our reviewer says that the 
documentation does not support that the criteria for code 87506 have been met. Our reviewer found the 
laboratory report does not support 6-11 targets were tested in this case. There is a more appropriate code to 
report for the documented service. 
 
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 87506 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87506 billed for date of service April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an air pressure mattress (E0186) provided by a skilled 
nursing facility on March 31, 2023. 
 
You asked the Plan to pay for an air pressure mattress. You say that the item should be covered. The Plan 
denied your request. The Plan says this item is not covered when obtained through a provider that is not 
enrolled as a DME supplier. 
 
The Plan must follow Medicare rules. Medicare rules say that a Durable Medical Equipment (DME) supplier 
must, among other things, meet the following conditions to be eligible to receive payment for a Medicare-
covered item: (i) the supplier has submitted a complete Form CMS-855S (including all supporting 
documentation) to the applicable contractor); and (ii) the item was furnished on or after the date the contractor 
issued to the supplier a DME supplier number conveying Medicare billing privileges.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an air pressure mattress have not been met. Specifically, this item was obtained through a provider that is not enrolled with Medicare as a DME supplier. Therefore, we decided that the Plan does not have to pay 
for an air pressure mattress (E0186) provided by a skilled nursing facility on March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481, 87500, 87640, 87652, 87653, 
87798, 87899, and 87900) provided on June 1, 2023. 
 
You asked the Plan to pay for the panel testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87500, 87640, 87652, 87653, 87798, 87899, and 87900 are not supported in the 
medical record. Specifically, a panel was performed and there is a more appropriate singular code for the 
services. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the panel testing (87481, 87500, 87640, 
87652, 87653, 87798, 87899, and 87900) provided on June 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0480, 80307, and 83789 billed for date of 
service June 1, 2023. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the billed codes 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. 
 
We find that CPT code 80307 is not supported in the medical records. The lab reports do not show that a 
presumptive test was provided. We find that CPT code 83789 is not supported. The testing described by billed 
code 83789 is considered specimen validity testing which is not separately payable. 
 
We find that CPT code G0480 is not supported. In this case, there are insufficient medical records to show that 
urine drug testing of 1-7 drug classes was ordered based on individual clinical history and risk assessment. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes G0480, 80307, and 83789 
billed for date of service June 1, 2023.