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

 
We decided that the Plan does not have to pay for EGD (43236) provided on January 30, 2023. 
 
You asked the Plan to pay for esophagogastroduodenoscopy. You say that CPT Code 43249 was done to dilate 
the esophagus, CPT code 43236 was done in the stomach for botox injection, and CPT code 43245 was done in 
the stomach for dilation of the (pyloric) stenosis. You say that two dilations were performed, but in different 
anatomical area; therefore, CPT code 43236 should be paid separately. The Plan denied your request. The Plan 
says CPT code 43236-59 (1 Unit) remains not supported. The Plan says this code is included in CPT code 
43245 and 43249, this means it cannot be separately reimbursed. The Plan says the medical records received do 
not support that the EGD (43236) was distinct or independent from other services performed; therefore, the use 
of the 59 modifier is not supported. The Plan states the billed CPT code 43236 and modifier 59 cannot be 
verified. 
 
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, we have confirmed that code 43236 is a column II code to column I code 43245 and 43249; 
however, 43236 was billed with a modifier.  
 
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 EGD (43236) on January 30, 2023. Our reviewer says that 
the medical records received do not support that the EGD was distinct or independent from other services 
performed; therefore, the use of the 59 modifier is not supported. The provider reported procedure code with 
appended modifier 59, which is a distinct procedural service to bypass NCCI Edit with the EGD (43236). 
However, the procedure report does not include documentation to support the procedure was distinct from the 
dilation procedure performed. Therefore, code (43236-59) denied appropriately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of esophagogastroduodenoscopy (43236) on January 30, 2023, have not been met. 
Therefore, we decided that the Plan does not have to pay for EGD (43236) provided on January 30, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy services. 
 
You asked the Plan to pre-approve the therapy services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not substantiate the need for these services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the records do not indicate a need for skilled therapy, based on 
the response to the therapy that's consisted of a repetitive exercise program. The enrollee is able to do a home 
exercise program. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued physical therapy services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (87481, 87500, 87511, 87640, 87653, 87798, 
87801) provided on April 8, 2023. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 lab testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the performed testing is not standard of care and not supported by national guidelines. 
 
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 lab testing have not been met. Therefore, we decided that the Plan does not 
have to pay for lab testing (87481, 87500, 87511, 87640, 87653, 87798, 87801) provided on April 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can be treated at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found although the enrollee requires routine physical and occupational therapy, he does not 
require an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitative care. His needs 
can be safely met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on February 27, 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 billed code cannot be verified. 
 
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 a medically appropriate history and/or examination and high level 
of medical decision making." 
 
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 decision making was 
not of high complexity. As such, the billing of CPT 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99285) rendered on February 27, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for 87801. We decided that the Plan does not have to pay for 87481, 
87653, and 87798.  
 
You asked the Plan to pay for procedure codes 87481, 87653, 87798, and 87801 rendered on February 27, 
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 87801.  
 
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 CPT 8801 is "Infectious agent 
detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique." 
 
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 87801. Our reviewer says that the laboratory 
report describes that multiple organisms were tested with amplified probe technique. Therefore, CPT 87801 is 
supported and verified. 
 
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 
87801.  
 
We also decided that the Plan does not have to pay for 87481, 87653, and 87798. 
 
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 the rest of the codes is: 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 
CPT 87653: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each 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 for these codes. Our reviewer says that the laboratory 
report does not include any documentation to support the use of modifier XU - unusual non-overlapping 
service - for these codes. The procedures were performed with the same method. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 87481, 87653, and 87798 have not been met. Therefore, we decided that the 
Plan does not have to pay for 87481, 87653, and 87798. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review.  The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we 
decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right total knee arthroplasty (27447).  
 
You asked the Plan to pre-approve a right total knee arthroplasty. You say that this service is medically 
necessary. The Plan denied your request. The Plan says the criteria are not met because the enrollee has not 
completed a six-week course of physical therapy focused on the right knee.  
 
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 right total knee arthroplasty. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that detailed documentation regarding a trial and failure of recent, 
reasonable, comprehensive, less invasive conservative care measures is not evident. There is no indication she 
has tried and failed any formal physical therapy. Additionally, there is no indication that the enrollee has tried and failed viscosupplementation injections. All reasonable forms of conservative treatment should typically be 
tried/documented prior to a knee joint replacement. There are limited large-scale, long-term references showing 
the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested right total knee arthroplasty is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a right total knee arthroplasty have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a right total knee arthroplasty (27447).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device (33289).  
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the enrollee needs this device due to 
worsening heart failure. The Plan denied your request. The Plan says there remains a dearth of randomized, 
blinded clinical studies examining the long-term clinical outcomes to establish the value of CardioMEMS in 
patient management.  
 
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 CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device (33289).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nuclear medicine parathyroid scan (78071).  
 
You asked the Plan to pre-approve a nuclear medicine parathyroid scan. You say that this service was 
medically necessary. The Plan denied your request. The Plan says parathyroid scan is medically necessary 
when parathyroid and calcium levels are elevated, and surgery is planned. The medical records provided, at 
prior authorization and on appeal, do not confirm that these conditions are present.  
 
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 nuclear medicine parathyroid scan. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the enrollee has recurrent kidney stones and may have 
hyperparathyroidism according to the submitted material but the chemical makeup of the stones, the serum calcium and parathormone levels are not in the submitted records. The medical necessity of parathyroid 
imaging has not been established in the submitted records. 
 
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 nuclear medicine parathyroid scan have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a nuclear medicine parathyroid scan (78071).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Afirma analysis rendered on March 2, 2023.  
You asked the Plan to pay for the services. You say that this claim must be processed according to the 
Medicare Clinical Laboratory Fee Schedule. The Plan denied your request. The Plan says the Bethesda score is 
required per the policy. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that it appears that the nodule was diagnosed as a benign nodule. The criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for Afirma analysis rendered on March 2, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and necessary. 
 
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 home ventilator. Our physician 
reviewer found there is no diagnosis of thoracic restrictive disease or neuromuscular disease. Medicare does 
not cover a home ventilator when used at settings that can be provided with bilevel positive airway pressure 
(BiPAP), and there are BiPAP devices that can provide the average volume-assured pressure support 
(AVAPS)-AE mode that has been ordered for the ventilator.  The record does not include documentation that 
BiPAP with AVAPS has been tried and failed as an outpatient. The denial is upheld. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve parathyroid planar imaging (78070). 
 
You asked the Plan to pre-approve parathyroid planar imaging. You say that parathyroid planar imaging is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that parathyroid planar imaging 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 parathyroid planar imaging. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has Vitamin D deficiency. The enrollee's parathormone level 
continues to rise each year and is definitely abnormal.  While the enrollee's serum calcium level is normal and 
neck ultrasound is negative, there are cases of parathyroid adenomas producing primary hyperparathyroidiism 
with normal calcium levels and adenomas in an ectopic location such as the mediastinum. The requested 
parathyroid multiplanar imaging is reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of parathyroid planar imaging have been met. Therefore, we decided that the Plan 
has to pre-approve parathyroid planar imaging (78070).  
 
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 inpatient hospital services reported with DRG 872 rendered 
from July 5, 2022, to July 16, 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 one or more of the billed diagnoses were not 
supported by the clinical records and did not impact the clinical resource utilization. 
 
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 872. 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 the documentation supports a diagnosis of sepsis, but not severe sepsis. The enrollee had systemic 
inflammatory response syndrome with cellulitis as a source, so sepsis is met, but no documentation of end 
organ dysfunction to meet criteria for severe sepsis. The documentation more supports DRG 603 rather than 
DRG 872.  
 
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 reported with DRG 872 rendered from July 5, 2022, to July 16, 2022.