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

 
We decided that the Plan does not have to pay for code 23650-54 billed for date of service April 21, 2023. 
 
You asked the Plan to pay for code 23650-54. You say that medical records were provided to support payment. 
The Plan denied your request. The Plan says the use of the 54 modifier for code 23650 is not supported by the 
medical record. The submitted medical records do not contain a written transfer agreement in alignment with 
the Split Surgical Package Policy 
 
The Plan follows Medicare rules. Medicare rules say that modifier 54 is to be used to indicate when the 
surgeon transfers all or part of the post-operative care to a provider outside their group.  This modifier applies 
when the surgeon fully transfers critical care services to another provider. 
 
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 23650-54. Our reviewer says that the 
use of the 54 modifier is not supported in this case. Our physician reviewer found you reported procedure code 
23650 with appended modifier 54-Surgical care only.  The medical record does not include documentation of transfer of post operative care to another provider.  For modifier 54, the surgeon must transfer postoperative 
care (partial or total) to another provider, and the surgical code with modifier 55 appended will be billed by the 
receiving provider to whom the postoperative care was transferred. Therefore, modifier 54 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 code 23650-54 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 23650-54 billed for date of service April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 6, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says this service is not covered when received by an 
OON 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 a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network physician services are not covered. 
 
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 office visit provided on June 6, 2023, by an 
OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 21, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary. 
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 R46.2 has an Excludes1 note in relation to F99. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay 
for ambulance services provided on May 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on July 11, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that the diagnoses billed are valid. 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 J44.9 has an Excludes1 note in relation to J43.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for 
oxygen equipment provided on July 11, 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 the enrollee requires rehabilitations services for the 
management of their complex medical needs. The Plan denied your request. The Plan says the enrollee does not 
meet the criteria 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that the enrollee suffers from knee pain 
that significantly affects their functionality and quality of life. You say that the enrollee has moderate to severe 
pain and has failed conservative treatments. The Plan denied your request. The Plan says the genicular nerve 
block 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 the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that genicular 
nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the 
treatment of chronic knee pain. 
 
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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management (99491) provided on September 
27, 2022. 
 
You asked the Plan to pay for 99491. You say that this claim was denied in error. The Plan denied your 
request. The Plan says the enrollee was registered as a hospital inpatient on this date of service, so the Place of 
Service (POS) code billed is not appropriate. 
 
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 99491 is chronic care management services with the 
following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or 
until the death of the patient, chronic conditions that place the patient at significant risk of death, acute 
exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, 
revised, or monitored; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month. 
 
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 99491. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the documentation submitted does not contain a note from the 
provider stating that chronic care management services were performed as part of a domiciliary, rest home, or 
home care plan. The documentation consists of notes justifying an inpatient stay. It cannot be confirmed that 
99491 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 99491 have not been met. Therefore, we decided that the Plan does not have to 
pay for chronic care management (99491) provided on September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0452 billed for date of service March 16, 
2023. 
 
You asked the Plan to pay for procedure code G0452. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code G0452 is bundled into payment for codes 83140, 
83142, and 81455. 
 
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 G0452 is a column II code to column I codes 83140, 83142, and 
81455. This Code G0452 was billed with the -59 modifier. The medical records do not show that the service 
billed with the -59 modifier was a distinct procedural 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 G0452 
billed for date of service March 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2023, to July 15, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary. 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2023, to July 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) on all 
4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the periodontal scaling and root planing 
with code D4341 is the correct code as the enrollee has pockets in more than 4 teeth. The Plan denied your 
request. The Plan says the denial of authorization for dental code D4341 is correct, because the procedure 
submitted is more accurately represented with the code of D4342. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the downgraded code correction is correct. Our physician reviewer found that there was a periodontal chart 
dated August 13, 2023, a narrative from the provider, and a full mouth series of x-rays. The x-rays are 
unreadable due to its graininess. I am unable to see the bone levels around all the teeth or see radiographic 
calculus due to the quality of the x-rays attached. Without clear x-rays, I am unable to determine medical 
necessity for the periodontal scaling and root planing (D4341) for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the periodontal scaling and root planing (D4341) on all 4 quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and psychotherapy (90833) provided 
on May 26, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the physician services. You say that the provider is contracted with Medicare and 
the enrollee's Plan. You say that you do not know why it has been removed from Medicare Plan. You also say 
that this was medically necessary. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99213) and psychotherapy (90833) provided on May 26, 2023, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99204-57 billed for date of service June 15, 2023. 
 
You asked the Plan to pay for the billed service. You say that the treatment of the fracture was performed on 
the same day as the evaluation. The Plan denied your request. The Plan says that code 99204 is included in the 
global surgery period for code 27750. 
 
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 code 99204-57 is supported in the medical record. CPT code 99204 was provided on the 
same day as major surgery code 27750. The medical records clearly document that after assessment, the 
decision was made to perform the procedure to stabilize the enrollees fracture. Based on this information, we 
decided that Medicare rules for coverage of the billed service have been met. Therefore, we decided that the 
Plan has to pay for procedure code 99204-57 billed for date of service June 15, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an amniotic membrane placement. 
 
 
You asked the Plan to pre-approve an eye surgery. You say that this surgery was medically necessary. 
 The Plan denied your request. The Plan says the rendered surgery was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an eye surgery have been met. Medical records were requested and not obtained. Therefore, we decided that the Plan does not have to pre-approve an 
amniotic membrane placement.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the colonoscopy with biopsy (45380), colonoscopy with directed 
submucosal injection(s) (45381), and associated services provided on June 14, 2023. 
 
You asked the Plan to pay for the diagnostic colonoscopy services. You say that you had a colonoscopy on 
December 6, 2021, and were advised you needed to have another every six months. You also say that you were 
not aware of the frequency limitation, and cannot afford this bill. The Plan denied your request. The Plan says 
that the maximum number of Outpatient Facility Preventive Services available under your coverage have been 
paid for by the Plan. 
 
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. The records do not support the Plans denial in this case. Specifically, the 
contract clearly states that a screening colonoscopy for people at high risk is covered every 24 months. The 
Plan applied these benefits incorrectly, as the record shows the colonoscopy services provided on June 14, 
2023, were diagnostic, and not screening. The Plan also has not provided any proof of the colonoscopy that the 
enrollee received on December 6, 2021, such as records and/or claim information. It is the burden of the Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated. Therefore, we 
decided that the Plan has to pay for the colonoscopy with biopsy (45380), colonoscopy with directed 
submucosal injection(s) (45381), and associated services provided on June 14, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
January 25, 2023, through February 14, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says a PCD is not covered for preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on January 25, 2023, through February 14, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Breast Cancer Index test panel (81518) performed for date of 
service March 22, 2023. 
 
You asked the Plan to pay for the Breast Cancer Index test panel. You say that this test was medically 
necessary and is supported in the records provided. The Plan denied your request. The Plan says that the 
documentation submitted did not include documentation that clearly identifies the genes tested to support this 
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. 
 
We find that CPT code 81518 is supported in the medical record. Specifically, the records indicate that the 
specific panel performed was the Breast Cancer Index test panel as provided by Biotheranostics, Inc. This test 
is listed in the DEX database as covered. This determination was made and is specific to the test at issue. The 
rules say that this test must be reported with CPT code 81518 and the appropriate DEX Z-Code, both of which 
have been reported on this claim. Based on this information, we decided that Medicare rules for coverage of the 
Breast Cancer Index test panel have been met. Therefore, we decided that the Plan has to pay for the Breast 
Cancer Index test panel (81518) performed for date of service March 22, 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 code 81345 billed for date of service May 31, 
2023. 
 You asked the Plan to pay for procedure code 81345. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 code 81345 billed for date of service May 31, 2023.