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

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on May 9, 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 CPT 99284 is not substantiated by the clinical documentation. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99284) rendered on May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on January 21, 2023. 
 
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 service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 44970 
provided on January 21, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the office visit rendered on January 
21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a heated humidifier (E0562) for a positive airway pressure 
(PAP) device. 
 
You asked the Plan to pay for a heated humidifier. You say that you have billed the reported item correctly. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided on the date of service reported 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for a heated humidifier (E0562) for a 
positive airway pressure (PAP) device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 19, 2022, to 
June 17, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted multiple 
times. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from May 19, 2022, to June 
17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospitalist visit provided on March 9, 2023. 
 
You asked the Plan to pay for hospitalist visit. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that J96.01 has an Excludes1 note in relation to R09.02. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for hospitalist visit have not been met. Therefore, we decided that the Plan does not have to pay for 
a hospitalist visit provided on March 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99232 rendered from May 16, 
2023, to May 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 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 99223: 
 
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 
 
CPT 99232: 
 
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 moderate level of medical decision 
making. When using total time on the date of the encounter for code selection, 35 minutes must be met or 
exceeded 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level or that at least 75 
minutes were spent, so CPT 99223 is not supported. Additionally, the documentation supports an appropriate 
exam, but not an appropriate history or medical decision making of moderate level, or that at least 35 minutes 
were spent, so CPT 99232 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99223 and 99232 rendered from May 16, 2023, to May 18, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for interrogation device evaluation(s) (remote), up to 90 days; single, dual, 
or multiple lead pacemaker system, or leadless pacemaker system with interim analysis, review(s) and report(s) 
by a physician or other qualified health care professional (code 93294) provided on April 20, 2023. 
 
You asked the Plan to pay for interrogation device evaluation(s) (remote), up to 90 days; single, dual, or 
multiple lead pacemaker system, or leadless pacemaker system with interim analysis, review(s) and report(s) 
by a physician or other qualified health care professional. You say that your doctor sent the referral letter to the 
Plan before the service was provided. The Plan denied your request. The Plan says that per the Medicare Local 
Coverage Article (LCA) A56662, this procedure can be done no more than once every 90 days. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a valid Medicare rule to substantiate their 
denial. The Medicare LCA the Plan used to make their decision does not apply to your jurisdiction. Therefore, 
we decided that the Plan has to pay for interrogation device evaluation(s) (remote), up to 90 days; single, dual, 
or multiple lead pacemaker system, or leadless pacemaker system with interim analysis, review(s) and report(s) 
by a physician or other qualified health care professional (code 93294) provided on April 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0427-RH, A0425-RH) provided on 
January 26, 2023. 
 
You asked the Plan to pay for ambulance services. You say that these services were necessary and should be 
paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 7, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for ambulance services have not been met. Therefore, 
we decided that the Plan does not have to pay for ambulance services (A0427-RH, A0425-RH) provided on 
January 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95886 and 95908 rendered on May 8, 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. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support that CPT 95908 was rendered in this case. Rather, the notes indicate that triggered electromyography 
(EMG) was done to evaluate for pedicle screw placement. This is considered to be an EMG service, and not a 
nerve conduction study/nerve conduction velocity (NCS/NCV). As a formal NCS/NCV was not performed the 
use of CPT 95908 would not be appropriate. Additionally, the records do not support that CPT 95886 was rendered in this case. This code reflects EMG done in addition to NCS/NCV. As NCS/NCV was not performed 
in this case, this CPT code cannot be said to have been coded/submitted to reflect the services provided. 
 
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 95886 and 95908 rendered on May 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing panel provided on February 2, 2023, and 
billed with codes 81209, 81216, 81223, 81238, 81241, 81242, 81249, 81250, 81279, 81298, 81305, 81307, 
81311, 81317, 81320, 81321, 81334, 81339, and 81345. 
 
You asked the Plan to pay for the genetic testing 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 genetic testing panel have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing panel provided on 
February 2, 2023, and billed with codes 81209, 81216, 81223, 81238, 81241, 81242, 81249, 81250, 81279, 
81298, 81305, 81307, 81311, 81317, 81320, 81321, 81334, 81339, and 81345.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 3.  
You asked the Plan to pre-approve a Freestyle Libre 3. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a Freestyle Libre 3. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the Libre 3 is prescribed and the 
Libre 2 and Dexcom g6 are preferred CGM brands. Why the Libre 2 is not an option for you is not clear but 
certainly a Dexcom g6 would provide continuous glucose readings and alerts as would a Libre 3. Hence, 
criteria for coverage of a Libre 3 are not met as you have not tried the Dexcom g6 from the records submitted. 
 
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 Freestyle Libre 3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Freestyle Libre 3.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 1, 2023, to 
March 30, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that this claim has no errors and you 
have followed all Medicare guidelines. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 1, 2023, to March 
30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on December 13, 2022, billed 
with codes 87798 (x13), 87481 (x4), 87640, 87653 and 87556. 
 
You asked the Plan to pay for the laboratory panel. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. In addition, urine polymerase chain reaction (PCR) testing is not considered medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that a 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 a laboratory panel that was not billed with a single panel 
code as required. In addition, the order provided shows that a single panel was requested, which lists one unit 
of code 87798 as the panel code. Based on this information, we decided that Medicare rules for coverage of the 
laboratory panel have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on December 13, 2022, billed with codes 87798 (x13), 87481 (x4), 87640, 87653 and 87556.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 1, 
2021, to January 31, 2021. 
 
You asked the Plan to pay for SNF care. You say that you are authorized to pursue payment for this claim. The 
Plan denied your request. The Plan says this claim was billed with Type of Bill (TOB) 210 indicating that the 
provider does not anticipate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that a Type of Bill (TOB) with the final digit of 0 
indicates that the provider does not anticipate payment for the claim.  
 
We looked at the file and Medicare rules. This claim was billed with TOB 210, meaning a skilled nursing 
facility (SNF) inpatient claim for which payment is not anticipated. Therefore, the Plan is not responsible for 
payment of the claim as it has been billed. Based on this information, we decided that Medicare rules for 
coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled 
nursing facility (SNF) care provided from January 1, 2021, to January 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87500, 87511, and 87640 for date of 
service April 21, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87500, 87511, and 87640. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 codes 87481, 87500, 87511, and 87640 are not supported in the medical record. Specifically, 
no medical records that include laboratory results and detailed procedure notes were provided. This means the 
clinical utility of the services performed could not be validated. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87500, 87511, and 87640 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87500, 87511, and 87640 
for date of service April 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 28, 2022, billed 
with codes 88305, 88311, 88313, 88342, 88341, 85097, 88184, 88185, 88189, 88237, 88262, 88280, 88291, 
88368, 88369, 88377, 81263, 81305, 81407, 81479, 81347, 81334, 81403, 81405, 81347, and 81176. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the 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 
September 28, 2022, billed with codes 88305, 88311, 88313, 88342, 88341, 85097, 88184, 88185, 88189, 
88237, 88262, 88280, 88291, 88368, 88369, 88377, 81263, 81305, 81407, 81479, 81347, 81334, 81403, 81405, 
81347, and 81176.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left partial right replacement surgery. 
 
You asked the Plan to pre-approve a left partial right replacement surgery. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria 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 a left partial right replacement surgery. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found a partial knee replacement is not appropriate because imaging shows 
degenerative joint disease (DJD) of the entire 3 compartments of the knee. There is too much DJD for a partial 
surgery.  
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 left partial right replacement surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a left partial right replacement surgery.