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 March 24, 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 claim was downcoded to CPT 99284. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high 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 enrollee was sent to the 
emergency department to get his regularly scheduled hemodialysis. Hemodialysis was provided and the 
enrollee was returned to his nursing home. The medical decision making was not of high 
complexity. Therefore, the billing of CPT 99285 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 emergency room services (procedure code 99284) rendered on March 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure 43499 rendered on March 21, 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 there is a more appropriate code to describe the services 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. 
 
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 procedure report documents 
"Long peroral endoscopic myotomy (POEM) procedure performed."  In this case, there is a more appropriate 
procedure code that would be reported for service provided. An unlisted esophagus procedure is an 
inappropriate code to report, when a more specific code exists. 
 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 43499 rendered on March 21, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services reported with DRG 870 rendered 
from August 18, 2022, to August 24, 2022. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay 
clinical validation audit shows that the provider has reported inpatient hospital services with the incorrect 
DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 870. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the Sepsis 3 criteria was not met as there was not a SOFA score of 2+ nor evidence of organ failure related 
to a dysregulated response. The discharge note did not list sepsis as a diagnosis. DRG 207, therefore, would be 
more supported for this admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services reported with DRG 870 rendered from August 18, 2022, to August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - periapical each additional radiographic image 
(D0230) provided on April 3, 2023. 
 
You asked the Plan to pay for the bitewings - four radiographic images (D0274), and intraoral - periapical each 
additional radiographic image. You say that you went to the dentist office and were told you that you would 
owe nothing. You also say that they did not say the services were only allowed 1 every 3 years. The Plan 
denied your request. The Plan says your benefit for the intraoral - periapical each additional radiographic image 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service April 3, 2023. You requested 2 
units of intraoral x-rays (D0220 and D0230) on April 3, 2023 and received the allowed frequency of 1 (D0220) 
on the appealed claim. Therefore, we decided that the Plan does not have to pay for an intraoral - periapical 
each additional radiographic image (D0230) provided on April 3, 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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for 
admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record supports a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery, endosteal implant, sinus augmentation, and 
occlusal guard (D9946, D4260, D6010, D7952) provided on March 17, 2022, to August 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for osseous 
surgery, endosteal implant, sinus augmentation, and occlusal guard (D9946, D4260, D6010, D7952) provided 
on March 17, 2022, to August 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9279, S1015, S8301, A4556, A4557, and 
A4649 billed for date of service May 3, 2023. 
 
You asked the Plan to pay for procedure codes A9279, S1015, S8301, A4556, A4557, and A4649. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
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 A9279, S1015, and S8301 have a Status Indicator of I on the Physician Fee 
Schedule. This means that procedure codes A9279, S1015, and S8301 are not valid for Medicare purposes. We 
find that procedure codes A4556, A4557, and A4649 have a Status Indicator of P on the Physician Fee 
Schedule. This means that procedure codes A4556, A4557, and A4649 are not separately payable. Based on 
this information, we decided that Medicare rules for coverage of procedure codes A9279, S1015, S8301, 
A4556, A4557, and A4649 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes A9279, S1015, S8301, A4556, A4557, and A4649 billed for date of service May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental case management and periodontics (D4700, D9631) 
provided on May 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
case management and periodontics (D4700, D9631) provided on May 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87801) provided on February 16, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the records provided support the services as 
billed.  The Plan denied your request. The Plan says the billed units 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 87801 is Infectious agent detection by nucleic acid, 
multiple organisms; amplified probe(s) 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 says that the criteria for 
coverage have not been met.  Our reviewer found Current Procedural Terminology (CPT) 87801 was reported 
with 3 units. CPT code 87801 represents a panel code including multiple organisms.  Only 1 unit of service 
would be appropriately billed for this procedure code.  
 
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 laboratory services (87801) provided on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical additional radiographic images 
(D0230 x 2) provided on February 13, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the services provided has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the services provided was exhausted on date of service February 13, 2023. Specifically, 
the Plan's contract states that one intraoral x-ray is covered per year. On this day, three intraoral x-rays were 
provided, one intraoral x-ray was paid for by the Plan. Therefore, you have exhausted the allowable benefit for 
this service. The subsequent intraoral radiographic images provided in this case are not payable. Therefore, we 
decided that the Plan does not have to pay for the intraoral-periapical additional radiographic images  
(D0230 x 2) provided on February 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0480, 80307 and 83789) provided on 
May 22, 2023. 
 
You asked the Plan to pay for drug testing. You say that these services were medically necessary and should be 
paid. The Plan denied your request. The Plan says code 83789 is not separately payable, and codes G0480 and 
80307 are not 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. Medicare rules also say that providers 
performing validity testing on urine specimens utilized for drug testing should not separately bill the validity 
testing. 
 
In this case, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures. The CPT Code Manual definition of code G0480 is drug test(s), 
definitive, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, the records provided do not include test 
results for any presumptive or screening drug tests. Without these results, we cannot verify the services were 
provided as billed. Code G0480 is not supported, as the records show that drugs from more than 7 classes were 
tested. There is a more appropriate code to report the services provided. In addition, we find that the testing 
described by code 83789 is not separately payable. Therefore, we decided that the Plan does not have to pay for 
drug testing services (G0480, 80307 and 83789) provided on May 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307, G0480, and 83789 provided on May 
22, 2023. 
 
You asked the Plan to pay for procedure codes 80307, G0480, and 83789. You say that you would like the Plan 
to reconsider their denial of payment. 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 80307 is Drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service. 
 
The definition of code G0480 is Drug test(s), definitive, utilizing (1) drug identification methods able to 
identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), 
including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and 
excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), 
(2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix 
effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-
matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative 
or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including 
metabolite(s) if performed. 
 
We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, the 
documentation provided for review support that drugs from more than 7 drug classes were tested in this case; 
therefore, there is a more appropriate code than G0480 to report the services provided. Additionally, the 
records do not show that the services described by code 80307 were performed. 
 
Medicare rules also say that providers performing validity testing on urine specimens utilized for drug testing 
should not separately bill the validity testing. We find that the testing described by 83789 is not separately 
payable. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 80307, G0480, and 
83789 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 80307, 
G0480, and 83789 provided on May 22, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 24, 2023. 
 
You asked the Plan to pay for the medical services. You say that you do not understand why your claim is 
insufficient. 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 R26.81 has an Excludes1 note in relation to R26.2. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the records provided support the need for a 
home ventilator. The Plan denied your request. The Plan says a home ventilator is not medically necessary for 
this patient because their needs can be met with an alternative device such as a BiPAP device with average 
volume-assured pressure support (AVAPS).  
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 a home ventilator is not medically necessary. Our physician reviewer found the enrollee has COPD, 
obstructive sleep apnea, and was recently hospitalized with COVID pneumonia. The enrollee was recovering 
from a COPD exacerbation at the time of developing COVID. The enrollee was treated with BiPAP in the 
hospital, but hypercarbia reportedly persisted. The enrollee has BiPAP at home but was reportedly not fully 
compliant. There are no pulmonary function tests to assess the severity of the COPD. There is no diagnosis of 
thoracic restrictive disease or neuromuscular disease. There is no arterial blood gas (ABG) done while stable to 
document chronic carbon dioxide (CO2) retention. If that is present, the patient may benefit from BiPAP with 
average volume assure pressure support (AVAPS) during sleep as an outpatient. The records do not show that 
this has been tried as an outpatient. Medicare does not cover a home ventilator when used at settings that can be 
provided with BiPAP. 
 
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.