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

 
We decided that the Plan does not have to pay for procedure code G0481 billed for date of service April 12, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the order and test was provided. The Plan denied 
your request. The Plan says the billed code is 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 G0481 is definitive drug testing of 8-14 drug classes. We 
find that CPT code G0481 is not supported in the medical record. The records do not show that the testing of 8-
14 drug classes were ordered based on medication side effects or inefficacy, suspicious behaviors, self-
escalation of dose, indications/symptoms of illegal drug use, evidence of diversion, or other clinician 
documented change in affect or behavioral pattern. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code G0481 billed for date of service April 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ESI. 
 
You asked the Plan to pre-approve the ESI. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the criteria for coverage have 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 pre-approve the ESI. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no documentation of thoracic radiculopathy, radicular pain and/or neurogenic 
claudication due to disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, 
producing foraminal or central spinal stenosis; or post-laminectomy syndrome. Therefore, the criteria for 
coverage have 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 ESI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an ESI.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen supply codes E1390 and E1392 billed for date of 
service May 6, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee required this equipment. The Plan 
denied your request. The Plan says the diagnosis code is not appropriate as a primary diagnosis. The Plan must follow Medicare rules. The rules say that another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code J12.82, defined as 
pneumonia due to coronavirus disease 2019. This code is not an appropriate primary diagnosis as the code has 
a Code first note indicating to code the underlying condition first. Based on this information, we decided that 
Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan does not have 
to pay for oxygen supply codes E1390 and E1392 billed for date of service May 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 17, 2023, to March 
18, 2023, billed with evaluation and management (EM) codes 99223 and 99233. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the level of care is 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 codes 99223 and 99233 is initial hospital inpatient or 
observation care, per day, for the evaluation and management of a patient, which requires a medically 
appropriate history and/or examination and high level of medical decision making. When using total time on 
the date of the encounter for code selection, 75 minutes must be met or exceeded, and subsequent hospital 
inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 50 minutes must be met or exceeded. 
 
We asked our physician 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the provided records in this case do 
not document 2 out of 3 of an extensive number of diagnoses or management options, an extensive amount and 
complexity of data reviewed and high risk of complication.  
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 17, 2023, to March 18, 2023, billed 
with evaluation and management (EM) codes 99223 and 99233.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
reasonable and necessary to solve the enrollee's chronic low back pain. The Plan denied your request. The Plan 
says the Intracept procedure is not medically necessary. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the cause of pain is not clear and there is no imaging showing only Modic 
changes without facet degenerative joint disease or stenosis.  
  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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high dose rate electronic brachytherapy and therapeutic 
radiology simulation-aided field setting. 
 
You asked the Plan to pre-approve the outpatient services. You say that this is the best option for the enrollee 
as it delivers a higher dose of radiation directly to the tumor while sparing healthy tissue nearby. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 outpatient services. Our reviewer 
says that the requested high dose rate electronic brachytherapy is not considered medically reasonable and 
necessary in this case. Our physician reviewer found there are insufficient long-term efficacy and safety data to 
support the routine use of electronic surface brachytherapy for treatment of the enrollee's condition. Therefore, the reviewer found that the requested high dose rate electronic brachytherapy 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 outpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve high dose rate electronic brachytherapy and therapeutic radiology simulation-
aided field setting.
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 you are unable to care for yourself and need to get 
back to being independent. The Plan denied your request. The Plan says your condition does not meet the 
Medicare guidelines.  The Plan says that the services needed may be provided safely in a lower 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections for pain management. 
 
You asked the Plan to pre-approve epidural steroid injections for pain management. You say that it is medically 
necessary. The Plan denied your request. The Plan says it is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ESI may be covered if certain criteria are met. 
 
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 epidural steroid injections for pain 
management. Our reviewer says that the service is not medically necessary. Our physician reviewer found there 
is no documentation of lumbar radiculopathy, radicular pain and/or neurogenic claudication due to disc 
herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or 
central spinal stenosis; or post-laminectomy syndrome. The review has determined that the enrollee does not 
meet the coverage criteria for this procedure. The enrollee does not meet any of the limitations/exclusions for 
this 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 epidural steroid injections for pain management have not been met. Therefore, 
we decided that the Plan does not have to pre-approve epidural steroid injections for pain management.
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 you are not getting better and need to go to a 
rehabilitation, your condition has gotten worse. The Plan denied your request. The Plan says your condition 
does not meet the Medicare guidelines.  The Plan says that the services needed may be provided safely in a 
lower 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 26, 2022, to 
August 5, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that A41.9 is 
supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says A41.9 is not supported in the documentation. 
 
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 principal diagnosis A41.9, defined as sepsis, 
unspecified 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 to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that principal diagnosis A41.9 is not supported in the 
documentation. Our physician reviewer found the enrollee presented with shortness of breath. They were found 
to have multifactorial respiratory failure (chronic obstructive pulmonary disease, congestive heart failure, and 
pneumonia) requiring bilevel positive airway pressure (BiPAP) support. While the enrollee was treated for 
pneumonia, it does not appear that this caused systemic illness or sepsis (i.e., hypotension, hypoperfusion, 
organ failure). As such, the billing of A41.9 is not supported.  
 
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 provided on July 26, 2022, to August 5, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87633) provided on December 19, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (87633) provided on 
December 19, 2022.
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 you are not able to care for yourself and needs to get 
stronger to return to your independence. The Plan denied your request. The Plan says your condition does not 
meet the Medicare guidelines.  The Plan says that the services needed may be provided safely in a lower 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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA), respiratory virus 12-25 targets (87633) provided February 27, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that this test was ordered by a treating physician 
who makes the professional determination of diagnosis and medical necessity to successfully treat their 
patients. The Plan denied your request. The Plan says does not meet Medicare coverage criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Current Procedural Terminology (CPT) 87633 is a Group 2 Code, 
and these codes are not covered. Based on this information, we decided that Medicare rules for coverage of the 
laboratory service have not been met. Therefore, we decided that the Plan does not have to pay for the 
infectious agent detection by nucleic acid (DNA or RNA), respiratory virus 12-25 targets (87633) provided 
February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 17, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that this code was reported appropriately and 
should be paid. The Plan denied your request. The Plan says payment for code 81456 is bundled into payment 
for code 81455. 
 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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 81456 billed for date of service February 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 6, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the diagnosis code at 
issue is not appropriate as a primary diagnosis.  
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code J12.82. This code 
is not an appropriate primary diagnosis. Based on this information, we decided that Medicare rules for payment 
of this claim have not been met. Therefore, we decided that the Plan does not have to pay for the services 
provided on June 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is at a high risk of injury 
without LTACH services. The Plan denied your request. The Plan says the LTACH services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that are not available at the health care 
setting being offered by the Plan. Given there are offered alternatives, LTACH is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 6, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not payable. 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 81456 billed for date of service February 6, 2023.