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

 
We decided that the Plan does not have to pay for the laboratory services (87798-59, 87653-59 and 87481-59) 
provided March 16, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are 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 87798 is infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. The definition of code 87653 is 
infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique. 
The 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 the laboratory services. Our reviewer found for code 87798, 
the documentation submitted was reviewed and does not meet criteria. The procedure represents, not otherwise 
specified, each organism. The medical record does not include documentation of each specific code reported 
for this procedure, and therefore, cannot be verified. For code 87653, the documentation submitted was 
reviewed and does not meet criteria. The provider reported a procedure code which includes multiple 
organisms, which would include this procedure when documented correctly. The medical record does not 
include documentation of each specific code reported for this procedure, and therefore, cannot be verified. For 
code 87481, the documentation submitted was reviewed and does not meet criteria. The provider reported a 
procedure code which includes multiple organisms, which would include this procedure when documented 
correctly. The medical record does not include documentation of each specific code reported for this procedure, 
and therefore, cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87798-59, 87653-59 and 87481-59) provided March 16, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 36558 and 76937 rendered on January 20, 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 that the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 36558: 
 
Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years 
or older 
 
CPT 76937: 
 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the documentation supports coding 
and coverage of both codes in question.  
 
In terms of CPT 36558, this codes for a tunneled central venous catheter.  There is satisfactory documentation 
that the catheter was both tunneled and placed centrally, specifically in the superior vena cava. 
 
In terms of CPT 76937, this codes for ultrasound guidance for vascular access. There is satisfactory 
documentation that ultrasound guidance was used to access the jugular vein. While there is a stipulation that 
the images must be archived, it is not reasonable to require documentation of this in the operative note. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure codes 36558 and 76937 rendered on January 20, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76937 provided on April 5, 2023. 
 
You asked the Plan to pay for procedure code 76937. You say that the medical records support the billing of 
code 76937. The Plan denied your request. The Plan says that the medical records do not support the billing of 
code 76937. 
 
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 76937 is Ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
separately in addition to code for primary procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 76937. Our reviewer says that the medical 
records support the billing of code 76937. Our reviewer found the documentation does state that there was 
ultrasound guided placement of a jugular vein and access was provided, therefore, code 76937 is 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 procedure code 76937 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 76937 provided on April 5, 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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve the occupational and physical therapy services (97535-GO) 
provided from March 20, 2023, through March 31, 2023. 
 
You asked the Plan to pre-approve the therapy services. You say that the enrollee was evaluated due to a 
decline in functional performance and independence with activities of daily living (ADLs).  The Plan denied 
your request. The Plan says that the requested services are not medically 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 pre-approve the therapy services. Our physician 
reviewer found the therapy that occurred from March 20, 2023, to March 31, 2023, was an initial episode of 
care pertaining to the enrollee's decreased ability to perform self-care tasks. The therapy services were an 
appropriate duration and frequency for treatment of the enrollee's medical condition and to establish a home 
exercise program and therefore, were 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 therapy services 
have been met. Therefore, we decided that the Plan has to pre-approve the occupational and physical therapy 
services (97535-GO) provided from March 20, 2023, through March 31, 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 codes 23650, 99152, and 99284 provided on 
February 12, 2023. 
 You asked the Plan to pay for procedure codes 23650, 99152, and 99284. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not 
support the services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 23650 is Closed treatment of shoulder dislocation, with 
manipulation; without anesthesia. The definition of code 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 23650 and 99152. Our reviewer says that 
the medical records do not support the billing of codes 23650 and 99152.  Our reviewer found there is no 
documentation that there was closed treatment of shoulder dislocation with manipulation without anesthesia, so 
code 23650 is not supported. Additionally, there is no documentation that moderate sedation services provided 
by the same physician or other qualified health care professional performing the diagnostic or therapeutic 
service that the sedation supports, requiring the presence of an independent trained observer to assist in the 
monitoring of the patient's level of consciousness and physiological status was provided so 99152 is not 
supported. 
 
In this case, we have also confirmed that code 99284 is a column II code to column I code 99152. The modifier 
billed is not supported in the records provided to bypass the edit. Based on the claim submitted, Medicare 
billing criteria have not been met. 
 
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 codes 23650, 99152, and 99284 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 23650, 99152, and 99284 provided on February 
12, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent detection services (U0003, U0005) provided 
on October 18, 2022. 
 
You asked the Plan to pay for infectious-agent detection. You say that the Plan is responsible for hospice 
services. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for infectious-agent detection services (U0003, U0005) provided 
on October 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 20, 2023, billed with code 
83036. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary.  The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on April 20, 2023, billed with code 83036.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of August 19, 
2023. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee's care can be safely provided in another 
setting. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet criteria for continued inpatient psychiatric care. Our physician reviewer 
found there is no indication that the enrollee's symptoms cannot be managed in a less restrictive setting. The 
enrollee had no acute psychiatric issues that would require continued inpatient level of care. The records do not 
support that continued inpatient care will change the enrollee's symptoms or current condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued inpatient psychiatric care as of August 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from August 24, 2022, to 
September 6, 2022.  
 You asked the Plan to pay for the home health services. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 26, 2022. The NOA was not received by the Plan until December 15, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from August 24, 2022, to September 6, 2022.
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 4, 
2023. 
 
You asked the Plan to pay for procedure code 99100. You say that the procedure is separately payable. 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 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 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 13121 and 13122 provided on December 6, 
2022. 
 
You asked the Plan to pay for procedure codes 13121 and 13122. You say that the medical records support the 
billing of codes 13121 and 13122. The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 13121 and 13122. 
 
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 13121 is Repair, complex, scalp, arms, and/or legs; 2.6 
cm to 7.5 cm. The definition of code 13122 is Repair, complex, scalp, arms, and/or legs; each additional 5 cm 
or less (List separately in addition to code for primary procedure). 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 13121 and 13122. Our reviewer says that 
the medical records do not support the billing of codes 13121 and 13122. Our reviewer found as summarized in 
the Current Procedural Terminology Manual, a complex wound closure involves repair of wounds requiring 
more than layered closure such as scar revision, debridement, undermining, stents or retention sutures. 
Provided records in this case document a layered closure (with no description of scar revision, debridement, 
undermining, stents or retention sutures); records support that the procedure on December 6, 2022, would more 
accurately be considered an intermediate repair.  
 
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 codes 13121 and 13122 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 13121 and 13122 provided on December 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 1, 2023, billed with 
codes 81162, 81218, 81209, 81201, 81295, 81292, 81272, 81314, 81307, 81298, 81334, 81321, 81317, 81479, 
81351, and 81345. 
 
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 
April 1, 2023, billed with codes 81162, 81218, 81209, 81201, 81295, 81292, 81272, 81314, 81307, 81298, 
81334, 81321, 81317, 81479, 81351, and 81345.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
October 10, 2022. 
 
You asked the Plan to pay for procedure codes 20930 and 20936. The Plan denied your request. The Plan says 
procedure codes 20930 and 20936 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 codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
October 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided October 16, 2022, through 
October 26, 2022. 
 You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 16, 2022. The NOA was not received by the Plan until March 7, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided October 16, 2022, through October 26, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0482 billed for date of service March 1, 2023. 
 
You asked the Plan to pay for the billed service. You say that the documentation supports the billing. The Plan 
denied your request. The Plan says that there is a more appropriate code that should be used.  
 
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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab reports do support that 
15-21 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the 
billed service have been met. Therefore, we decided that the Plan has to pay for procedure code G0482 billed 
for date of service March 1, 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.