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

 
We decided that the Plan does not have to pay for procedure code 12001 billed for date of service June 7, 2023.  
 
You asked the Plan to pay for procedure code 12001. You say that you disagree with the Plan's denial. 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 12001 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 12001 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 12001 billed for date of service June 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from October 6, 2021, to 
November 3,2021. 
 
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 the claim was paid correctly. 
 
The Plan must follow Medicare rules. The rules say that after a RAP has been paid and a 60-day episode has 
been completed, or the patient has been discharged, the HHA submits a claim to receive the balance of 
payment due for the episode. 
 
We looked at the file and Medicare rules. The file shows that the Plan paid the claim based on the submitted 
RAP. 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 home health services rendered from 
October 6, 2021, to November 3,2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
interspace; lumbar (22612). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records do not show that the enrollee completed and failed 2 types of 
conservative care for at least 6 weeks in the last 6 months. 
 
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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has not undergone updated imaging after the previous foraminotomy at L3-4 on 
March 24, 2023. Dynamic flexion/extension films are not provided in order to potentially assess the amount of movement (instability) at the requested surgical level. Detailed documentation is not evident regarding 
potential impending/inevitable temporary intra-operative instability. Therefore, the requested posterior 
arthrodesis of the lumbar at L3-4 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis, posterior or posterolateral technique, single interspace; lumbar (22612).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for a computed tomography (CT) scan with 
renal biopsy with a tertiary level provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no reason that this cannot be done by one of the primary network providers. 
 
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 the referral. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that assuming the in network providing hospital has qualified interventional radiologists there is no 
reason the requested CT guided biopsy could not be done by an in network providing radiology department. 
 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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral for a computed tomography (CT) scan with renal biopsy with a tertiary level 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  assistant surgeon services for codes 19301 and 76998 for 
date of service  
 
You asked the Plan to pay for  assistant surgeon services for codes 19301 and 76998. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the records do not clearly document the 
assistant surgeon's role during the operative session and therefore medical necessity for assistant at surgery has 
not been established. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 19301 and 76998. The Medicare Fee Schedule Database contains a surgical indicator 
of 0 for this 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 to pay for assistant surgeon services for codes 19301 
and 76998. Our reviewer says that the documentation does not support the need for the surgical assistant 
services provided. Our physician reviewer found the enrollee had left intraoperative needle localization 
lumpectomy and local soft tissue advancement flaps. The documentation does not detail the assistant surgeon's 
role during the operation and why it was medically necessary. Therefore, the services rendered were not 
medically 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 assistant surgeon services for codes 19301 and 76998 have not been met. 
Therefore, we decided that the Plan does not have to pay for  assistant surgeon services for codes 19301 and 
76998 for date of service
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve SI RFA. You say that the medical records support this request. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that SI joint radiofrequency ablation is not considered 
reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SI RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve 
sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 12, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 12, 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 enrollee lives alone and is unable to return home 
until they can regain their prior level of mobility and strength. The Plan denied your request. The Plan says 
admission to an IRF is not medically necessary.  
 
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 enrollees nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. 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. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement. However, the documentation does not support that they would meet criteria for 
admission to an IRF.  There is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehabilitation services 15 hours a week, under the supervision of a physician with at least 3 
visits weekly to regain or maintain their functional status.  The enrollee can receive further services 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676, E0673), provided 
on November 8, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the items were medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676, E0673), provided on November 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 9, 2022, billed with 
codes 87150, 87798, 87640, 87653, and 87482. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 9, 2022, billed with codes 87150, 87798, 87640, 87653, and 87482.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that the patient requires non-invasive ventilation due to a failure of BiPAP with persistent hypercarbia secondary to chronic pulmonary disease. The Plan denied your request. The Plan says this request for a home mechanical ventilator set in intelligent volume-assured pressure support (iVAPS) mode with auto-expiratory positive airway pressure (EPAP) that could be delivered by BiPAP is not covered.

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 a home ventilator. Our reviewer says that this request is not medically necessary. Our physician reviewer found the record indicates that the patient has chronic hypercarbic respiratory failure from COPD and obesity hypoventilation syndrome. The record indicates that the patient was successfully treated with BiPAP. Our reviewer found that the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure support (AVAPS) capability and failure of such a device has not been documented. Our physician reviewer also found that the Plan has indicated coverage for such a device is available upon request.

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient-only practitioner services provided on May 24, 
2023. 
 
You asked the Plan to pay for inpatient-only services. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says code 19361 is an inpatient-only procedure. All other claim 
lines denied as services provided on same day as inpatient procedure. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 19361. This code is listed with a status indicator of 
C on Addendum B of the 2023 OPPS/ASC final rule. This means the service has been designated as inpatient only, and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for the inpatient-only practitioner services provided on May 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 1, 2023, to June 15, 
2023. 
 
You asked the Plan to pay for the home health services. You say that you believe this claim was billed 
correctly. The Plan denied your request. The Plan says you did not bill an appropriate Type of Bill code for 
these services. 
 
The Plan must follow Medicare rules. Medicare rules say that home health agencies must bill the correct type 
of bill code.  Except for replacement or voided claims, home health agencies must bill type of bill 0329.  In this 
case, you billed with the incorrect type of bill code of 0323. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided from June 1, 2023, to June 15, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99215, 93976, 94621, 94010, 95012, 
A4617, 71048, 94664, and 99072 billed for date of service January 5, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed codes 
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 99215 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and high level of medical decision making.   
 
We find that CPT code 99215 is not supported. The medical records show that the enrollee was seen for a 
follow up for chronic obstructive respiratory disease. The records do not show that a high level of decision 
making was provided. Based on this information, we decided that the Medicare rules for coverage have not 
been met. 
 
The definition of code 93976 is duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal 
contents and/or retroperitoneal organs; limited study. The definition of code 94621 is cardiopulmonary exercise 
testing, including measurements of minute ventilation, CO2 production, O2 uptake, and electrocardiographic 
recordings. The definition of code 94010 is spirometry, including graphic record, total and timed vital capacity, 
expiratory flow rate measurement(s), with or without maximal voluntary ventilation. The definition of code 
95012 is nitric oxide expired gas determination. The definition of code 71048 is radiologic examination, chest; 
4 or more views. The definition of code 94664 is demonstration and/or evaluation of patient utilization of an 
aerosol generator, nebulizer, metered dose inhaler or IPPB device.  
 
We find that CPT cods 93976, 94621, 94010, 95012, 71048, and 94664 are not supported in the medical 
record. Specifically, the records do not include documentation that these tests were provided on the date of 
service at issue. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. We find that procedure code A4617 has a status indicator of 
X. This means that code A4617 is not payable.  
 
We looked at the file and the rules. 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 codes 99215, 93976, 
94621, 94010, 95012, A4617, 71048, 94664, and 99072 billed for date of service January 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transcatheter implantation of wireless pulmonary 
artery pressure sensor (33289). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the CardioMEMS device has not 
been demonstrated in the peer-reviewed literature. 
 
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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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 enrollee's 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the transcatheter implantation of wireless pulmonary artery pressure sensor (33289).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481 (5 units) billed for date of service 
November 9, 2022. 
 
You asked the Plan to pay for procedure code 87481 (5 units). You say that these services were necessary and 
were reported appropriately. The Plan denied your request. The Plan says this code is not supported as billed. 
Only 4 units are supported in the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 87481 is infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe 
technique. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 87481 (5 units). Our reviewer says that this 
code is not supported for the number of units billed. Our reviewer found only 4 units are supported in the 
laboratory report, and the additional unit 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 procedure code 87481 (5 units) have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 87481 (5 units) billed for date of service November 9, 2022.