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

 
We decided that the Plan does not have to pay for procedure code 36556 rendered on February 14, 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 Current Procedural Terminology (CPT) code 36556 rendered on February 14, 2023. 
 
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 36556 is "Insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older." 
 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 CPT code 36556 is not supported. 
The record does not contain evidence that the line terminated in the subclavian, brachiocephalic, iliac, vena 
cava, or right atrium. This is a requirement for reporting 36556. 
 
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 36556 rendered on February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) rendered 
on October 5, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) 99152 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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
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 record does not support the 
use of this sedation code. That code requires detail of the amounts and time of sedative administration as well 
as vital signs recording. These items are not present. 
 
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 moderate sedation services (procedure code 99152) rendered on October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (DNA or RNA), 
not otherwise specified; amplified probe technique, each organism rendered on March 3, 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 there is a more appropriate code for this 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 87798 is "Infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified; amplified probe technique, each organism." 
 
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 laboratory report documents 
that multiple organisms were tested. In this case, a more appropriate and more highly specific code should have 
been reported. 
 
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 infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified 
probe technique, each organism rendered on March 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from May 27, 2022, to 
June 2, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay 
clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
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 DRG 454. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that there is no clear documentation to support a diagnosis code of D62. This would require documentation of 
an acute hemorrhagic event and subsequent anemia. The documentation supports DRG 455 rather than DRG 
454.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services rendered from May 27, 2022, to June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99205) rendered on 
November 17, 2022. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says the documents do not support this level of care. 
 
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 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 visit. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the documentation from this visit 
supports a medically appropriate history and examination. Biopsy of the lip was performed which was well 
tolerated. The records do not, however, support a high level of medical decision-making nor was there 
documentation of the duration of the appointment being 60-74 minutes to justify the code - CPT 99205. 
 
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 visit have not been met. Therefore, we decided that the Plan does not have 
to pay for an office visit (procedure code 99205) rendered on November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of procedure code 88291 rendered from 
November 28, 2022, to November 2, 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 additional documentation or confirmation that indicates or supports additional testing. 
 
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 88291 is "Cytogenetics and molecular cytogenetics, 
interpretation and report." 
 
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 treating provider billed 4 units 
(2 for each day) whereas only one unit per day is allowed. There was no provided clinical information that 
supports this testing was done on those dates or why the use of more than one unit for each of these days of 
treatment was utilized. Therefore, this request for such will be considered not medically necessary. 
 
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 additional units of procedure code 88291 rendered from November 28, 2022, to November 2, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter/crutch substitute described by code 
E0118. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is at risk for falls. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a crutch substitute described by code E0118 is 
denied as not medically necessary. 
 
We looked at the file and Medicare rules. The item at issue is a knee scooter/crutch substitute described by 
code E0118. This item is denied by Medicare as not medically necessary. Therefore, we decided that the Plan 
does not have to pre-approve a knee scooter/crutch substitute described by code E0118.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 rendered on February 23, 
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. 
 
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 medical record describes an 
insulin infusion service provided (Outpatient Intravenous Insulin Treatment - OIVIT).  In this case, there is a 
more appropriate Healthcare Common Procedure Coding System (HCPCS) that would be reported for service provided. Therefore, these procedure codes 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 96365 and 96366 rendered on February 23, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for G0108. We decided that the Plan does not have to pay for 96365 and 
96366.  
 
You asked the Plan to pay for procedure codes 96365, 96366 and G0108 rendered on November 30, 2022.. 
You say that this should be paid for. The Plan says that these codes are not appropriate for the services billed. 
 We decided that the Plan has to pay for G0108.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of Healthcare Common 
Procedure Coding System (HCPCS) G0108 is "Diabetes outpatient self-management training services, 
individual, per 30 minutes." 
 
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 G0108. Our reviewer says that the procedure report 
documents "Direct counseling for 20 minutes, reinforced diet, lifestyle changes, medications and adherence to 
monitoring blood sugars, daily weights. Reviewed blood sugar log and most recent lab results with patient." 
This procedure should be covered, as counseling on self-management was documented in the procedure report. 
 
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 
G0108.  
 
We also decided that the Plan does not have to pay for 96365 and 96366. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The denied of the upheld codes is: 
 
CPT 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 
 
CPT 96366: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(List separately in addition to code for primary procedure) 
 
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 these codes. Our reviewer says that these codes are 
incorrect for reporting intravenous insulin treatment. There is a more appropriate code to report for the services 
provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 96365 and 96366 have not been met. Therefore, we decided that the Plan does 
not have to pay for 96365 and 96366. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo to be used in combination with Paclitaxel and 
Carboplatin. 
 
You asked the Plan to pre-approve the drug. You say that the enrollee never received first line chemotherapy as 
intended due to severe 5-FU toxicity The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that there was previous progression Opdivo. The requested three drug regimen is not an evidence-based regimen. The only evidence-
based regimen is FOLFOX plus Opdivo, which has been failed. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Opdivo to be used in combination with Paclitaxel and Carboplatin.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary and mandibular reconstruction and placement 
of dental implants. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The member handbook specifically denies coverage for implants and 
fixed dentures. Therefore, we decided that the Plan does not have to pre-approve maxillary and mandibular 
reconstruction and placement of dental implants.
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 June 
29, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 99223 remains not supported, as the documents do 
not support this level of care. 
 
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, per day, for the evaluation 
and management of a patient, which requires these 3 key components: 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 problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the progress note for 6/29/22 does 
not contain a comprehensive history. No separate history and physical is identified. The documentation does 
not support the billing of 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 June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99205) rendered on 
November 17, 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 the documents do not support this level of care. 
 
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 99205 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter." 
 
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 laryngeal endoscopy with biopsy 
was performed without complication. Although the history and physical were appropriate, the records do not 
support a high level of medical decision-making on this date, nor was there a documented duration of this 
visit/procedure being 60-74 minutes long to justify the code - CPT 99205.  
 
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 an office visit (procedure code 99205) rendered on November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 rendered on February 21, 
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 the denied codes is: 
 
CPT 96365: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 
 
CPT 96366: 
 
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour 
(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 CPT codes 96365 and 96366 are 
not supported. The record states that a continuous insulin infusion was performed with monitoring of glucose. 
There is a more specific code to report these services. 
 
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 codes 96365 and 96366 rendered on February 21, 2023.