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

 
We decided that the Plan does not have to pay for procedure codes S9351, S9375, and S9379 billed for date of 
service December 24, 2022, to December 30, 2022. 
 
You asked the Plan to pay for procedure codes S9351, S9375, and S9379. You say that this should be paid for. 
The Plan denied your request. The Plan says the billed codes are 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 codes S9351, S9375, and S9379 have a Status Indicator of I on the Physician Fee 
Schedule. This means that these procedure codes are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure code S9351, S9375, and S9379 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes S9351, S9375, and 
S9379 billed for date of service December 24, 2022, to December 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on January 
16,2023. 
 
You asked the Plan to pay for the hospital care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim was not billed with a valid primary diagnosis 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 99233 is not supported in the medical record. Specifically, diagnosis code R65.2 has a 
code first note and the underlying diagnosis was not coded first. Based on this information, we decided that 
Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does 
not have to pay for subsequent hospital care (99233) provided on January 16,2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
28, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
23, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 23, 2022.
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 admission to IRF is medically necessary. The Plan 
denied your request. The Plan says admission to IRF is not medically necessary. 
 
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. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee stable and suitable for 
transfer. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care 
and does not require transfer to a Long-Term Acute Care Hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 57250 billed for date of service February 2, 
2023.  
 
You asked the Plan to pay for procedure code 57250. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 57250 is bundled into payment for code 57240. 
 
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 57250 is a column II code to column I code 57240 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 57250 billed for date of service February 2, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 18, 2023, billed with 
code 74176. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code assigned by the 
physician/practitioner for the PC of a diagnostic service shall be the setting in which the beneficiary received 
the TC service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. The file shows that the enrollee was an inpatient 
on the date of service. As such, the outpatient POS code 22 is not appropriate. Therefore, we decided that the 
Plan does not have to pay for imaging services provided on January 18, 2023, billed with code 74176.
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's condition and current functional 
deficits, as well as multiple comorbidities, meets full Inpatient Acute Rehabilitation criteria. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an Inpatient 
Rehabilitation Facility. 
 
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. 
 
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: 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. The Plan denied your request. The Plan says  the enrollee does not 
meet the Medicare criteria for admission to an Inpatient Rehabilitation Facility. 
 
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. 
 
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 pay for procedure code S9328 billed for date of service January 29, 
2023, to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary and 
ordered by a network doctor. 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 January 29, 2023, to February 25, 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 do not meet the Medicare criteria for admission 
to an Inpatient Rehabilitation Facility. The Plan denied your request. The Plan says the enrollee's records does 
not meet all the required criteria for admission to an Inpatient Rehabilitation Facility. 
 
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. 
 
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 pay for procedure code A4263 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code A4263. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code A4263 is considered bundled and 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 procedure code. 
 
We find that procedure code A4263 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4263 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4263 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4263 billed for date of service August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 8, 2022, and  
December 15, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the supporting 
diagnosis codes are for routine foot care not related to diabetes. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit 
provided on December 8, 2022, and December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (77523). 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that proton beam radiation therapy 
is a medical necessity for the enrollee. The Plan denied your request. The Plan says proton beam radiation 
therapy is experimental/investigational. 
 
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 proton beam radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that whether proton therapy affords a benefit over other standard approaches for 
prostate cancer is an area of investigation and remains controversial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy (77523).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service January 13, 
2023. 
 You asked the Plan to pay for procedure code 71045. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 71045 is bundled into payment for code 32555. 
 
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 71045 
is a column II code to column I code 32555. 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 71045 billed for date of service January 13, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 71045-TC billed for date of service 
September 17, 2022. 
 
You asked the Plan to pay for procedure code(s) 71045-TC. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this code is included in the skilled nursing facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 71045-TC has a Professional/Technical indicator of 1. This means that CPT code 71045-
TC has both a professional and technical component. In this case, CPT code 71045-TC has not been billed with 
an appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 71045-TC have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code(s) 71045-TC billed for date of service September 17, 2022.
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 February 17, 
2023, to February 25, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were medically necessary and 
ordered by an in-network doctor. 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 February 17, 2023, to February 25, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 94618 and 99072 billed for date of service 
July 18, 2022.  
 
You asked the Plan to pay for procedure codes 94618 and 99072. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says payment for code 94618 is bundled into 
payment for code 94621. The Plan also says code 99072 has a status indicator of B and is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 94618 
is a column II code to column I code 94621 with a modifier indicator of 0. The column II code is therefore not 
payable. Procedure code 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable.  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 94618 and 99072 
billed for date of service July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 62368 billed for date of service December 
13, 2022.  
 
You asked the Plan to pay for procedure code 62368. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 62368 is bundled into payment for code 62370. 
 
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 62368 
is a column II code to column I code 62370 with a modifier indicator of 0. The column II code is therefore not payable. 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 62368 billed for date of service December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99233 billed for date of service September 
18, 2022.  
 
You asked the Plan to pay for procedure code 99233. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99233 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99233 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99233 billed for date of service September 18, 2022.