Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 11, 2023, 
through 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 that the acute inpatient hospital care provided 
was not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee was brought to the emergency department (ED) on February 11, 2023 for the evaluation 
of aggressive behavior. He was evaluated with a history and physical exam and laboratory studies. He was 
noted to have an abnormal urinalysis and was treated with intravenous antibiotics and admitted. He was 
evaluated by Psychiatry and medication was started. His condition stabilized and improved and he was 
considered medically stable for discharge back to the nursing facility on February 13, 2023. The review has 
determined that the record showed that at the time of the inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from February 11, 2023, through February 13, 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: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81551 and 88387 billed for date of service 
March 31, 2023. 
 
You asked the Plan to pay for the billed services. You say that the testing is a covered benefit. The Plan denied 
your request. The Plan says the diagnosis codes should not be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We find that CPT codes 81551 and 88387 were billed with diagnosis codes D29.1 and N40.1. Diagnosis code 
D29.1 has an Excludes1 note that includes diagnosis code group N40. 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 codes 81551 and 88387 billed for date of service March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87640 billed for date of service October 20, 
2022. 
 
You asked the Plan to pay for procedure code 87640. You say that these services were reported correctly and 
are supported in the medical record. The Plan denied your request. The Plan says this code is not supported for 
separate payment. 
 
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 87640 is a column II code to column I code 87641; however, 87640 
was billed with a modifier.  
 
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 87640. Our reviewer says that this code is 
not supported for separate payment. Our reviewer found the laboratory report does not support that this was an 
unusual non-overlapping service. CPT 87640 would be included in CPT 87641. 
 
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 87640 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87640 billed for date of service October 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 21, 2022, to July 
20, 2022. 
 You asked the Plan to pay for the home health services. You say that you submitted the NOA after the claim 
was submitted.  However, these services were medically necessary and 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 February 21, 2022. The NOA was not received by the Plan until February 
5, 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 home health services provided 
from June 21, 2022, to July 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on January 2, 2023. 
 
You asked the Plan to pay for the testing. 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 testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on January 2, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T2046 billed for date of service March 1, 
2023, to March 31, 2023. 
 
You asked the Plan to pay for procedure code T2046. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
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 T2046 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T2046 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T2046 billed for date of service March 1, 2023, to March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 120 units of code 01402 billed on March 14, 2023. 
 
You asked the Plan to pay for 120 units of code 01402. The Plan denied your request. The Plan says the 
number of billed units is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 120 units of code 01402 Our reviewer says 
that the records do not support 120 units of code 01402. Our physician reviewer found that the procedure report 
documents "Anesthesia Start 9:50; Stop 11:40". A total of 110 minutes of anesthesia time is supported, which 
does not support the 120 units billed for code 01402. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 120 units of code 01402 have not been met. Therefore, we decided that the Plan 
does not have to pay for 120 units of code 01402 billed on March 14, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97140 billed for date of service November 
11, 2021. 
 
You asked the Plan to pay for procedure code 97140. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 97140 is bundled into payment for 
code 29581. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
In this case, we have confirmed that code 97140 is a column II code to column I code 29581. Code 97140 was 
billed with a modifier; however, there is insufficient information in the case record to determine if use of the 
modifier is warranted in this case. Specifically, medical records to support procedure code 97140 have not been 
provided. Therefore, we decided that the Plan does not have to pay for procedure code 97140 billed for date of 
service November 11, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for methadone-assisted treatment services (G2067) provided on April 13, 
2023. 
 
You asked the Plan to pay for methadone-assisted treatment services. You say that you have billed the services 
at issue correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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's denial indicates that the provider of the services at issue 
is not a properly certified provider. However, we found that the provider is listed as a federally certified opioid 
treatment program on the government-maintained website FindTreatment.gov. It is the Plan's responsibility to 
support its denial with evidence. In this case, the Plan's denial has not been supported, so we must find in your 
favor. Therefore, we decided that the Plan has to pay for methadone-assisted treatment services (G2067) 
provided on April 13, 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: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653, 87798, and 87641, 
billed for date of service August 17, 2022. 
 You asked the Plan to pay for procedure codes 87150, 87481, 87653, 87798, and 87641. The Plan denied your 
request. The Plan says payment for codes 87150, 87481, 87653, 87798, and 87641, is bundled. 
 
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 87150 
is a column II code to column I code 87500. We have also confirmed that codes 87481, 87653, 87798, and 
87641, are column II codes to column I code 87150. 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 codes 87150, 87481, 
87653, 87798, and 87641, billed for date of service August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on January 30, 2023, billed 
with procedure codes 96365-59, 96366-59, and 96521. 
 
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 documentation does not support the billed codes. 
 
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 96365-59, 96366-59, and 96521 is intravenous infusion, 
for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, intravenous infusion, for 
therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition 
to code for primary procedure), and refilling and maintenance of portable pump. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the record states that a continuous 
insulin infusion was performed with monitoring and guidance related to blood glucose. According to coding 
rules, there is a more specific code to report this procedure. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on January 30, 2023, billed with procedure 
codes 96365-59, 96366-59, and 96521.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Depuy Synthes Lifenet Vivigen Allograft (20930).  
 
You asked the Plan to pre-approve Depuy Synthes Lifenet Vivigen Allograft. You say that the enrollee is in 
severe pain which is affecting ability to perform activities of daily living. The Plan denied your request. The 
Plan says the clinical value and effectiveness of the Depuy Synthes Lifenet Vivigen Allograft in the setting of 
posterior lumbar interbody fusion surgery have not been demonstrated in the peer- reviewed literature.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Depuy Synthes Lifenet Vivigen 
Allograft. 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 limited published, large-scale, long-term 
peer-reviewed literature that shows this requested allograft to be an effective and/or safe treatment for the noted pathology. Further studies are needed to demonstrate this request has beneficial outcomes compared with 
conventional treatment. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested Vivigen Allograft 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 Depuy Synthes Lifenet Vivigen Allograft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Depuy Synthes Lifenet Vivigen Allograft (20930).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 15, 2022, to May 
14, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was submitted 
timely. 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 January 12, 2022. The NOA was not received by the Plan until June 1, 
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 April 15, 2022, to May 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232, 99153 billed for date of service 
October 7, 2022, to October 11, 2022. 
 
You asked the Plan to pay for procedure code 99232, 99153. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says payment for code 99232, 99153 was not 
reported correctly. 
 
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, records indicate a National Correct 
Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 32560 and 99232. This PTP edit 
has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an 
appropriate NCCI modifier was not billed with this PTP code edit. For procedure code 99153, it shows a 
Professional Component (PC)/Technical Component (TC) Indicator 3. Code 99153 was established as a PE-
only code meaning there is no work component RVU associated with that service. 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 99232, 99153 billed for date of service October 7, 2022, to October 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arterial cannulation (36620) and anesthesia (99140) provided 
on March 4, 2023.  
You asked the Plan to pay for 36620 and 99140. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says 36620 is not supported by the records and code 99140 has a Status 
Indicator of B so is 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 36620 is arterial catheterization or cannulation for 
sampling, monitoring, or transfusion; percutaneous. 
 
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 36620 and 99140. Our reviewer says that code 36620 is not 
supported. Our reviewer found the record does not state that arterial cannulation for sampling, monitoring, or 
transfusion was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 36620 have not been met. We find that procedure code 99140 has a status 
indicator of B on the Physician Fee Schedule. This means that procedure code 99140 is not separately payable. 
Based on this information, we decided that Medicare rules for coverage of 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for arterial cannulation (36620) and anesthesia (99140) provided 
on March 4, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (93042) provided on December 23, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that cardiovascular stress tests include insertion of 
needle and/or catheter, infusion/injection (pharmacologic stress tests) and ECG strips (e.g., CPT codes 36000, 
36410, 96360-96379, 93000-93010, 93040-93042). These services shall not be reported separately.  
 
We looked at the file and Medicare rules. Per Medicare rules, the ECG strips are not separately payable. 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 the services (93042) provided on December 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 30, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this service 
is not covered because it was provided OON without a referral from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 30, 
2023, by an out-of-network (OON) provider.