Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99232) provided from July 2, 2022, to July 10, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed 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 99232 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit". 
 
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 use of code 99232 is 
not supported by the records provided. Our reviewer found that the documentation supports an appropriate 
exam, but not an appropriate history or medical decision making of moderate level, or at least 25 minutes spent 
at bedside for the dates of service in question. 
 
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 the services (99232) provided from July 2, 2022, to July 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power elevating leg rest and electronic connection 
device for a power wheelchair. 
 
You asked the Plan to pre-approve power elevating leg rest and electronic connection device. You say that 
these are needed to meet the enrollee's needs. The Plan denied your request. The Plan says these components 
are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve power elevating leg rest and electronic 
connection device. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the documentation does not indicate that the enrollee 
has a medical need for the power elevating leg rests or electronic connection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power elevating leg rest and electronic connection device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power elevating leg rest and electronic 
connection device for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from February 26, 2023, to 
March 2, 2023.  
 
You asked the Plan to pay for the medical services . You say that this should be paid as billed.  The Plan denied 
your request. The Plan says the incorrect POS code was reported.  
 
The plan must follow Medicare rules. The rules say that claims for services rendered to registered outpatients 
must report the appropriate outpatient facility POS code for the services. 
 
We looked at the file and Medicare rules. This claim was billed with an inpatient POS code, and the claim 
history shows that the enrollee was an outpatient. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for the medical services provided from February 26, 2023, to March 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous laminectomy. 
 
You asked the Plan to pre-approve a percutaneous laminectomy. You say that you can barely walk or sit for a 
length of time.  The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a percutaneous laminectomy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a percutaneous laminectomy is experimental, and more research is needed. 
 
 
 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 percutaneous laminectomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a percutaneous laminectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 36217, 36222, 36223, and 36224 rendered 
on August 8, 2022. 
 
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. 
 
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 in terms of CPT 36217, the 
procedure report describes a cervicocerebral angiography with intervention.  The procedure was performed through same access site.  In this case, this procedure would be included in 
angiography and intervention, and separate billing cannot be verified. In terms of the rest of the codes, the 
provider reported these procedure codes with appended modifier 59 for distinct procedural service from CPT 
61650. However, the documentation does not support these codes and the modifier reported. Per the CPT 
guidelines, CPT 61650 should be not reported in conjunction with 36221, 36222, 36223, 36224, 36225, 36226, 
61640, 61641, 61642, or 61645 for the same territory. 
 
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 36217, 36222, 36223, and 36224 rendered on August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87641 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code 87641. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this code is not supported for separate 
billing. 
 
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 87641 is a column II code to column I code 87801; however, 87641 
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 87641. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the documentation provided does not support that this 
service was unusual and non-overlapping with the primary procedure. Therefore, the modifier and code are not 
supported in this case. 
 
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 87641 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 87641 billed for date of service April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87653, 87798, and 87481 billed for date of 
service December 9, 2022. 
 
You asked the Plan to pay for procedure codes 87653, 87798, and 87481. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for codes 87653, 87798, and 87481 is 
bundled into payment for code 87801. 
 
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 codes 
87653, 87798, and 87481 are column II codes to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. 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 87653, 87798, and 87481 
billed for date of service December 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 3, 2023, 
through January 6, 2023. 
 
You asked the Plan to pay for the home health services. You say that this claim was billed per CMS guidelines. 
The Plan denied your request. The Plan says payment is not allowed for this home health claim because it 
contains invalid data or is missing data which is required per CMS. 
 
The Plan follows Medicare rules. The rules say that HHAs must report where home health services were 
provided. 
 
We reviewed the file and the Medicare rules. We find that home health claims require a G code and a Q code. 
The records show that this claim does not include the Q code. 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 January 3, 2023, through January 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 20, 2023, billed with 
evaluation and management (EM) code 99204-57-25. 
 
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 code. 
 
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 99204-57-25 is office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter. 
 We asked our physician to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the documentation does not support 
an appropriate exam, an appropriate history or medical decision making of moderate level. Documentation 
does not support that at least 45 minutes were spent on the care. Procedure code 99204 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on March 20, 2023, billed with evaluation and 
management (EM) code 99204-57-25.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on October 8, 2021, to October 12, 
2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says that documentation 
does support the billed diagnosis. 
 
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 secondary diagnosis code A41.89, described as 
other specified sepsis. 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 documentation does support the billed diagnosis. 
Our physician reviewer found that the enrollee had systemic inflammatory response syndrome with bacteria 
which meets the definition for sepsis from urinary tract infection. As such, secondary diagnosis code of A41.89 
is justified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on October 8, 2021, to October 12, 2021, at the Diagnosis Related Group (DRG) 
originally billed.  
 
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 intravenous infusion, (96365, 96366) and refilling and 
maintenance of portable pump (96521) provided on January 25, 2023. 
 
You asked the Plan to pay for intravenous infusion and refilling and maintenance of a portable pump. You say 
that the enrollee received infusions as well as maintenance/refill of pump. See attached medical records to 
support dispute. The Plan denied your request. The Plan says codes 96365-59, 96366-59, 96521 all remain not 
supported. 
 The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 intravenous infusion and refilling and 
maintenance of a portable pump. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found for CPT 96365, documentation submitted was reviewed, and does not meet criteria. Procedure 
report describes intravenous insulin treatment provided for an outpatient. In this case, there is a more 
appropriate healthcare common procedure coding system (HCPCS) code that should be reported for service 
provided. For CPT 96366, documentation submitted was reviewed, and does not meet criteria. Procedure report 
describes intravenous insulin treatment provided for an outpatient. In this case, there is a more appropriate 
HCPCS code that should be reported for service provided. For CPT 96521, documentation submitted was 
reviewed, and does not meet criteria. Procedure report includes a physician order for this procedure; however, 
performance of this procedure was not documented in procedure report and therefore cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intravenous infusion and refilling and maintenance of a portable pump have not 
been met. Therefore, we decided that the Plan does not have to pay for intravenous infusion, (96365, 96366) 
and refilling and maintenance of portable pump (96521) provided on January 25, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87801 provided on February 28, 2023. We decided that 
the Plan does not have to pay for procedure codes 87481, 87653, & 87798 provided on February 28, 2023.  
 
You asked the Plan to pay for procedure codes 87481, 87653, 87798, & 87801 provided on February 28, 2023. 
You say that the services were medically necessary. The Plan says that the documentation does not support the 
billed services. 
 
We decided that the Plan has to pay for procedure code 87801 provided on February 28, 2023.   
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
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 code 87801. Our reviewer says that the 
records provided support the billed code. Our physician reviewer found that the records support Infectious 
agent detection by nucleic acid, multiple organisms, amplified probe technique was performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87801 have been met. Therefore, we decided that the Plan has to pay for 
procedure code 87801 provided on February 28, 2023.  
 
We also decided that the Plan does not have to pay for procedure codes 87481, 87653, & 87798 provided 
on February 28, 2023. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed.  
 
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 procedure codes 87481, 87653, & 87798. 
Our reviewer says that these codes are not supported by the provided records. Our physician reviewer found 
that the lab report does not support the modifier billed for these codes. Records do not show that these codes 
are a separate procedure from code 87801. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87653, & 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653, & 87798 provided on February 
28, 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 the hospital physician services provided on February 25, 
2023.  
 
You asked the Plan to pay for the services at issue. You say that this was medically necessary care and should 
be paid.  The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.   
The Plan must follow Medicare rules. Medicare rules say that certain diagnosis codes have Code First notes 
which indicates that they should not be sequenced before the code for the etiology of the condition.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code I26.90, defined as 
septic pulmonary embolism without acute cor pulmonale. This code has a Code first note indicating that the 
underlying infection should be reported first. As such, this is not an appropriate primary diagnosis code. Based 
on this information, we decided that Medicare rules for coverage of the services at issue have not been met. 
Therefore, we decided that the Plan does not have to pay for the hospital physician services provided on 
February 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service February 8, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87798. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these services 
are not supported for separate billing/reporting. 
 
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 87481, 87653 and 87798 is a column II code to column I code 87801; 
however, 87481, 87653 and 87798 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 codes 87481, 87653 and 87798. Our reviewer says 
that these codes are not supported as separate services. Our reviewer found the documentation provided does 
not include sufficient information to support that these services were unusual and non-overlapping with the 
primary procedure. Therefore, the modifier is not supported, and the separate billing of these codes are 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 procedure codes 87481, 87653 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service February 8, 2023.