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

 
We decided that the Plan does not have to pay for dialysis services for Acute Kidney Injury (AKI) (90993, 
90999, 99512, J1756) provided on March 1, 2023, through March 13, 2023. 
 
You asked the Plan to pay for dialysis services. You say that you are requesting reconsideration and have 
submitted medical records for review. The Plan denied your request. The Plan says the provider did not bill as 
required by Medicare coding regulations. 
 
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 the dialysis services are not supported as billed. Specifically, this claim does not include the 
required HCPCS code or condition code. Based on this information, we decided that Medicare rules for 
coverage of dialysis services have not been met. Therefore, we decided that the Plan does not have to pay for 
dialysis services for Acute Kidney Injury (AKI) (90993, 90999, 99512, J1756) provided on March 1, 2023, 
through March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99223) provided on January 27, 2023. 
 
You asked the Plan to pay for the hospital care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 care, for the evaluation and 
management of a patient, requiring a comprehensive history, a comprehensive examination, and medical 
decision making of high complexity. 
 
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 hospital care. Our reviewer says that the billed code is 
not supported by the records provided. Our reviewer found the records do not show a comprehensive history or medical decision making of high complexity. 
 
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 hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for hospital care (99223) provided on January 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87798, 87498, 87502 and 87634) 
provided on December 22, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
laboratory services (87798, 87498, 87502 and 87634) provided on December 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a follow-up inpatient consultation (G0407) provided on 
November 29, 2022. 
 
You asked the Plan to pay for a follow-up inpatient consultation. You say that you are requesting 
reconsideration and have submitted supporting documentation for review. The Plan denied your request. The 
Plan says the provider billed code G0407 with POS 21 instead of POS 02. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. These 
services must be billed with POS 02 to identify the telehealth technology used to provide the service.  
 
We find that CPT code G0407 is not supported. Specifically, Medicare rules say that although follow-up 
inpatient telehealth consultations are specific to telehealth, these services must be billed with POS 02 to 
identify the telehealth technology used to provide the service. The records show that POS 21 was submitted on 
the claim instead of POS 02. Based on this information, we decided that Medicare rules for coverage of a 
follow-up inpatient consultation have not been met. Therefore, we decided that the Plan does not have to pay 
for a follow-up inpatient consultation (G0407) provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99214-25 and G3002 billed for April 27, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says code 99214 is not separately payable and code G3002 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 
99214-25 provided on April 27, 2023. We find that the service at issue may be unrelated to the surgical 
procedure; however, the required modifier to indicate this was not used. As such, the billing rules for these 
services have not been met.  
 
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 G3002 is chronic pain management and treatment, 
monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating 
scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan 
that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation 
and coordination of any necessary behavioral health treatment; medication management; pain and health 
literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care 
coordination between relevant practitioners furnishing care, e.g. physical therapy and occupational therapy, 
complementary and integrative approaches, and community-based care, as appropriate. 
 
We find that CPT code G3002 is not supported in the medical record. Specifically, there is no documentation 
of a monthly bundle of chronic pain management and treatment. 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 procedure codes 99214-25 and G3002 billed for 
April 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87652 for date of service April 13, 2023. 
 
You asked the Plan to pay for procedure code 87652. 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 87652 is infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group A, quantification. 
 
We find that CPT code 87652 is not supported in the medical record. Specifically, the medical records do not 
provider a quantification for the result for this service. Based on this information, we decided that Medicare 
rules for coverage of procedure code 87652 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 87652 for date of service April 13, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Medtronic BMP Infuse allograft (20930). 
 
You asked the Plan to pre-approve a Medtronic BMP Infuse allograft. You say that this is medically necessary. 
The Plan denied your request. The Plan says there is insufficient reliable evidence in the form of high-quality 
peer-reviewed medical literature to establish the safety and efficacy of the requested product for use in 
posterior fusion procedures. 
 
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 Medtronic BMP Infuse allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature 
that shows this requested allograft to be an effective and/or safe treatment. Further studies are needed to 
demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 Medtronic BMP Infuse allograft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Medtronic BMP Infuse allograft (20930).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided March 14, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that you are appealing the denial of Current 
Procedural Terminology (CPT) code 81151: ConfirmMDx for prostate cancer. The Plan denied your request. 
The Plan says the criteria has not been met for ConfirmMDx. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found per the CMS LCD, ConfirmMDx is considered when the patient is not being considered for a 
second prostate biopsy due to persistent risk factors such as rising PSA. The test was ordered on the same day 
as the initial biopsy and not to evaluate the need for second biopsy with the first biopsy being negative. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for ConfirmMDx testing (81551) provided March 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast procedure provided on February 10, 2023, billed 
with code 19499. 
 
You asked the Plan to pay for the services as billed. You say that no modifier is required for this service. The 
Plan denied your request. The Plan says the claim was not billed with a modifier to identify which side of the 
body the service was performed on.  
 
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 19499 is unlisted procedure, breast. 
 
We find that CPT code 19499 is not supported in the medical record. Specifically, no modifier was used to 
indicate the laterality of the procedure. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the 
breast procedure provided on February 10, 2023, billed with code 19499.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), electronic connection (E2311) to control power tilt, recline and power elevating leg rests 
through the joystick, and an accessory bar (K0108). 
 
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick, 
and an accessory bar (K0108). You say that the requested items/services are considered medically reasonable 
and necessary in this case. The Plan denied your request. The Plan says the requested items/services are not 
considered medically reasonable and necessary in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 an expandable controller (E2377), 
expandable controller harness (E2313), and an electronic connection (E2311) to control power tilt, recline and 
power elevating leg rests through the joystick. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found an expandable 
controller is an electronic system that can accommodate one or more additional features and can operate 3 or 
more powered seating options. The requested electrical accessories are not medically necessary as the member 
does have use of the upper extremity and can operate and control the power options using the switches that are 
included in the basic wheelchair. There is not a medical need for the upgraded electronics. Additionally, the 
requested accessory bar (K0108) does not serve a purpose that is primarily medical in nature. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller (E2377), expandable controller harness (E2313), electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick, 
and an accessory bar (K0108) have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller (E2377), expandable controller harness (E2313), electronic connection 
(E2311) to control power tilt, recline and power elevating leg rests through the joystick, and an accessory bar 
(K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that the power wheelchair you currently have is an 
outdoor wheelchair and too big to maneuver through your home. You also say that the rehabilitation center has 
recommended for you to have a 3 wheeled scooter. The Plan denied your request. The Plan says you were seen 
by an expert, and it was recommended for you to have a power wheelchair as it is the most appropriate mobility 
device for you. The notes do not show that a powered operated vehicle (scooter) is appropriate, so this request 
has been denied. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
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 scooter. Our reviewer says that the 
documentation does not support the medical necessity of a power scooter.  Our physician reviewer found the 
enrollee has musculoskeletal illness and diabetes. She uses a wheelchair, and the Plan has approved a power 
wheelchair. There is no medical evidence a scooter is necessary for MRADLs rather than the approved power 
wheelchair. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation (A0425, A0428) provided on 
March 19, 2023. 
 
You asked the Plan to pay for ambulance transportation. You say that the enrollee was transported from the 
hospital to a psychiatry facility as psychiatry services were not available at the first facility. The Plan denied 
your request. The Plan says on the date of service, the enrollee was in an inpatient hospital status. 
 
The Plan must follow Medicare rules. Medicare rules say that hospital bundling rules exclude payment to 
independent suppliers of ambulance services for beneficiaries in a hospital inpatient stay.  
 We find that CPT codes A0425, A0428 are not supported. Specifically, the records show that the enrollee was 
inpatient from March 14, 2023, to March 20, 2023. Medicare rules say that ambulance services used for 
transportation of a hospital inpatient to another facility is considered part of the inpatient admission and is not 
separately payable. Based on this information, we decided that Medicare rules for coverage of ambulance 
transportation have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
transportation (A0425, A0428) provided on March 19, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 17250 provided on January 24, 2023 
 
You asked the Plan to pay for procedure code 17250. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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 17250 is Chemical cauterization of granulation tissue (ie, proud flesh). 
 
We find that CPT code 17250 is supported in the medical record. Specifically, the records show that the 
chemical cauterization was provided on the left buttock, and modifier 59 is supported as procedure code 17250 
was performed on a different area than the debridement services. Based on this information, we decided that 
Medicare rules for coverage of procedure code 17250 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 17250 provided on January 24, 2023  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 9, 2022, 
through May 31, 2022. 
 
 
  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient hospital care provided 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 these services. 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 with multiple myeloma presented to the emergency department (ED) for a 
planned beginning of Dara-VRD (Daratumumab-Velcade, Revlimid, and Dexamethasone) treatment due to 
cytopenia. He reported a little blurry vision and chronic dizziness. He was found to be clinically stable and was 
given the treatment without complication. Based on the provided documentation, the enrollee was not expected 
to require hospital care that would have likely crossed 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from May 9, 2022, through May 31, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve a skilled nursing facility 
 
You asked the Plan to pre-approve the admission. You say that medical records are attached to support medical 
necessity. The Plan denied your request. The Plan says that they did not render a decision within the allotted 
timeframe. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Despite multiple requests for additional information, the plan has not sent in any 
medical records for review. The appellant has stated that they provided medical records that support medical 
necessity. Therefore, we decided that the Plan has to pre-approve a skilled nursing facility  
 
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.