Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the occupational therapy services provided from May 12, 2023, to June 
15, 2023. 
 
You asked the Plan to pay for the therapy services. You say that you would like the documentation to be 
reviewed and the denial to be overturned in full. The Plan denied your request. The Plan says that the 
documentation indicates that the initial denial was issued as not reasonable and necessary. 
 
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 pay for the therapy services. Our reviewer says that 
the occupational therapy services provided were medically necessary. Our physician reviewer found the 
requested occupational therapy is generally accepted as a specific and effective therapy reduced upper 
extremity range of motion and function with daily activities, including dressing and toileting. The patient 
received occupational therapy from May 12, 2023, to June 15, 2023, to address these deficits. Our reviewer 
also found that the documentation indicates that the patient made objective progress in terms of improving their 
upper extremity range of motion and their level of independence with performing toileting and dressing daily 
activities. 
 
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 been met. Therefore, we decided that the Plan has to 
pay for the occupational therapy services provided from May 12, 2023, to June 15, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 26, 
2023.  
 
You asked the Plan to pay for procedure code 86077. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGx Comprehensive Complete Cancer panel provided on 
February 4, 2022, and billed with codes 81201, 81295, 81298, 81317, 81403, 81404, 81405, 81406, 81407, and 
81408. 
 
You asked the Plan to pay for the CGx Comprehensive Complete Cancer panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the CGx Comprehensive Complete Cancer 
panel have not been met. Therefore, we decided that the Plan does not have to pay for the CGx Comprehensive 
Complete Cancer panel provided on February 4, 2022, and billed with codes 81201, 81295, 81298, 81317, 
81403, 81404, 81405, 81406, 81407, and 81408.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code E0675 billed for date of service December 6, 
2022. 
 
You asked the Plan to pay for the billed service. You say that the device aids in treatment of post-operative 
lymphedema. The Plan denied your request. The Plan says the request is not a covered benefit. 
 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 E0675 is not supported. A PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service and excluded from coverage. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code E0675 billed for date of service December 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 52005, 52315, 52344, and 76000 rendered 
on April 18, 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 denied codes remain 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 the denied codes is: 
 
CPT 52005: 
 
Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, 
exclusive of radiologic service 
 
CPT 52315: 
 
Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate 
procedure); complicated 
 
CPT 52344: 
 
Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, 
electrocautery, and incision) 
 
CPT 76000: 
 
Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time 
 
In this case, we have confirmed that codes 52005 and 52315 are  column two codes to column one code 52352 
with a modifier indicator of 0. The column two code is therefore not payable. Based on the claim submitted, 
Medicare billing criteria have not been met. 
 
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 for CPT 52344 and CPT 76000. Our reviewer says that CPT code 
52344 is not supported as a separate and distinct procedure from 52352. The record does not support that this 
procedure is separately identifiable from the cystourethroscopy with treatment of calculus. CPT 76000 is not 
supported. According to NCCI rules, fluoroscopy is inherent to many procedures and is not separately 
reportable. Based on NCCI rules, 76000 is inherent to 52352 and shall not be reported separately. 
 
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 52005, 52315, 52344, and 76000 rendered on April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88108 billed for date of service May 30, 
2023. 
 You asked the Plan to pay for procedure code 88108. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 88108 is bundled into payment for code 88173. 
 
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 88108 
is a column II code to column I code 88173. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 88108 billed for date of service May 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on April 7, 2023, to 
April 14, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says 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 DRG 637. 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 billed DRG is not supported by the records provided. Our physician reviewer found that the enrollee 
was admitted to the hospital for nausea, vomiting, abdominal pain, and chest pain only while swallowing food 
for the prior 2 days. Mild elevation in troponin was noted. Type 2 myocardial infarction was not supported in 
the documentation. The enrollee did not exhibit typical or even atypical anginal symptoms as the chest pain 
was only when swallowing which doesn't meet the criteria for the myocardial infarction diagnosis. The enrollee 
was diagnosed with severe erosive esophagitis and gastritis which explained the symptoms. The patient was 
otherwise was stable. Therefore, DRG 637 is not supported. DRG 639 is more appropriate for this admission.  
 
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 the inpatient hospital services provided on April 7, 2023, to April 14, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on May 2, 2023. 
 
You asked the Plan to pay for the psychotherapy services. You say that it is difficult to find a trauma therapist 
without having to tell your whole story all over again, which could re-traumatize you and make your therapy needs longer.  The Plan denied your request. The Plan says the supervising provider has opted out of Medicare 
and the provider supplying direct treatment is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. The rules also say that Medicare payment cannot be 
made to a provider that is not enrolled in the Medicare program. A Master of Social Work is not eligible to 
enroll in Medicare. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. This provider states that they were acting as a supervisor to a Licensed 
Master Social Worker (LMSW) who actually provided direct treatment. LMSWs are not eligible to enroll in 
Medicare. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on 
May 2, 2023.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 36581. We decided that the Plan does not have to pay for 36010.  
 
You asked the Plan to pay for procedure codes 36010 and 36581 rendered on March 20, 2023. You say that this 
should be paid for. The Plan says that the denied codes remain not supported. 
 
We decided that the Plan has to pay for 36581.   
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 36581 is "Replacement, 
complete, of a tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through 
same venous access." 
 
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 36581. Our reviewer says that this codes for 
replacement of an existing tunneled central venous catheter. There is satisfactory documentation that the 
service was rendered as there is documentation that subcutaneous tissues were infiltrated with lidocaine and the 
catheter possessed a cuff. Additionally, the line that was replaced was present for more than just a few days. 
Based on this information, the documentation has demonstrated to a reasonable degree that the catheter was a 
replacement of an existing tunneled catheter with a fresh tunneled catheter.  
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for 36581.  
 
We also decided that the Plan does not have to pay for 36010. 
 
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 36010 is "Introduction of 
catheter, superior or inferior vena cava." 
 
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 36010. Our reviewer says that this codes for a 
vena cava catheterization.  This is a component of the tunneled catheter replacement code.  It is not separately 
reportable. 
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for 36010. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 3, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that the services were patient specific and physician 
directed. The Plan denied your request. The Plan says the billed services are not supported. 
 
The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. 
 
In this case, the CPT Code Manual definition of code 96521 is refilling and maintenance of portable pump. We 
find that code 96521 is not supported in the medical record. The records do not document the refilling and 
maintenance of a portable pump. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pay for the Outpatient Intravenous Insulin 
Therapy (OIVIT) services provided on July 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Pigmented Lesion Assay (0089U) provided March 2, 
2023. 
 
You asked the Plan to pay for the genetic testing. You say that based on the information provided along with 
supporting documentation that clearly shows medical necessity, you request overturn of the denial and reprocessing of the claim. The Plan denied your request. The Plan says this service does not meet the Medicare 
medically necessary criteria. 
 
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 the Pigmented Lesion Assay is considered investigational and experimental. 
 
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 the Pigmented Lesion Assay (0089U) provided March 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
April 13, 2023, and billed with codes 87481, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on April 13, 2023, and billed with codes 87481, 87798, and 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 57283 and 52281 billed for date of service 
June 29, 2023. 
You asked the Plan to pay for the billed services. You say that the records describe the procedures in detail. 
The Plan denied your request. The Plan says payment for code 57283 is bundled into payment for code 58260. 
 
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 57283 is a column II code to column I code 58260. Code 57283 was 
billed with the -59 modifier. The medical records do not show that the service billed with the -59 modifier was 
a distinct procedural service. The records do not show that code 57283 was provided on a separate site not 
ordinarily encountered on the same day as the main procedure. 
 
In this case, the CPT Code Manual definition of code 52281 is cystourethroscopy, with calibration and/or 
dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for 
cystography, male or female. We find that code 52281 is not supported. The medical records do not document 
the calibration and/or dilation of a urethral stricture. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 57283 and 
52281 billed for date of service June 29, 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 the requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the records do not show that the enrolllee needs to be seen by a 
rehabilitation doctor at least 3 times per week for evaluation of functional and medical goals and progress. The 
records do not indicate the enrollee needs an intensive team for their 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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. There is not a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot insert, foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the 
requested foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot insert, foot orthotics.