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

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service May 4, 2023. 
 
You asked the Plan to pay for procedure code 99223. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says the service at issue was not billed with the required 
modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. For major surgeries, this also includes the day before surgery. Evaluation and management services on the day before or day of major 
surgery that result in the initial decision to perform surgery are not included in the global surgery payment, and 
such services may be billed and paid separately with modifier -57 appended.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 63266 
provided on May 5, 2023. We find that the service at issue may have resulted in the initial decision to perform 
the surgical procedure; however, the required modifier to indicate this was not used. As such, the billing rules 
for these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 99223 billed for date of service May 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 heavy duty power wheelchair with a single 
power option. 
 
You asked the Plan to pre-approve a Group 3 heavy duty power wheelchair with a single power option. You 
say that the enrollee is unable to ambulate and is at severe risk for skin breakdown associated with prolonged 
sitting. You also say that the only appropriate equipment for the enrollee is a power wheelchair that can be 
operated with a joystick that will also provide the ability to reposition and offload pressure on their own. The 
Plan denied your request. The Plan says the enrollee does not require the single power option. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with a single power 
option may be covered when certain criteria are met. 
 
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 Group 3 heavy duty power wheelchair 
with a single power option. Our reviewer says that the requested Group 3 heavy duty power wheelchair with a 
single power option is not medically necessary. Our physician reviewer found there is inadequate clinical 
documentation regarding why the enrollee requires power tilt and cannot perform pressure relief. The enrollee 
has no history of skin breakdown and is noted to have 4/5 motor strength in the upper extremities. Group 3 
power wheelchairs are typically indicated for those with total paralysis, such as with spinal cord injury. 
Therefore, the reviewer found that the requested Group 3 power wheelchair with power tilt is not medically 
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 a Group 3 heavy duty power wheelchair with a single power option have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 heavy duty power 
wheelchair with a single power option.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the fusion of the great toe provided by an 
in-network provider on October 26, 2022.   
 
You asked the Plan to waive the deductible for the fusion of the great toe. You say that you do not agree with 
the cost sharing. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $400 deductible which applies to in and out-of-network outpatient 
surgery services. 
 
 You have been asked to pay a $247.62 deductible for the fusion of the great toe. The item or service you asked 
the Plan to waive the deductible for falls within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $400 deductible which applies to outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a 
contractual obligation that had not been met at the time the fusion of the great toe was provided on October 26, 
2022. Therefore, we decided that the Plan does not have to waive the deductible for the fusion of the great toe 
provided by an in-network provider on October 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methazolamide. 
 
You asked the Plan to pre-approve Methazolamide. You say that the medication is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Methazolamide.  
 
Benefits for Methazolamide may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you are in a lot of pain and that you were told 
by your provider that the orthotics should help. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 18, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 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 81456 is a column II code to column I code 81455 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. Please note that the NCCI 
indicator charge that you reference has not yet was not officially implemented until October 1, 2023. This date 
is well prior to your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service April 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing billed with codes 80307 and G0480 and the 
validity testing billed with code 83789 for date(s) of service March 8, 2023.  
 
You asked the Plan to pay for codes 80307, G0480, and 83789. You say that this service is medically necessary 
and should be paid. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that providers 
performing validity testing on urine specimens utilized for drug testing should not separately bill the validity 
testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 has not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable.  
 
Additionally, the CPT Code Manual definition of code 80307 is Drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service.  The definition of code G0480 
is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. 
 
In this case, the physician order provided is incomplete. There is no evidence that presumptive testing was 
requested, and although a custom definitive panel with a file name appears to have been requested, there is no 
documentation providing details of which drugs are requested in the listed panel. Based on this information, we 
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing billed with codes 80307 and G0480 and the validity testing billed with 
code 83789 for date(s) of service March 8, 2023.
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's wound care needs can only 
be met in a LTACH setting.  The Plan denied your request. The Plan says the enrollee is receiving the 
appropriate inpatient acute care and currently unstable for transfer to a LTACH. 
 
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 the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure codes 99232 
and 99233) rendered from April 27, 2023, to May 1, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 99232: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision 
making. When using total time on the date of the encounter for code selection, 35 minutes must be met or 
exceeded 
 
CPT 99233: 
 
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of moderate level, or that 35 
minutes were spent, so code 99232 is not supported. 
 
Additionally, the documentation supports an appropriate exam, but not an appropriate history or medical 
decision making of high level, or that 50 minutes were spent, so code 99233 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure codes 99232 and 99233) rendered from April 
27, 2023, to May 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says an 
LTACH admission is not medically necessary.  
 
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 that the enrollee's needs are met in their current setting with no therapeutic advantage 
offered by a transfer to an LTACH. 
 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 28, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to 1, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 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 81456 
is a column II code to column I code 81455 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. Please note that the NCCI 
indicator change that you reference was not officially implemented until October 1, 2023. This date is well 
prior to your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the right to 
submit the claim again for additional consideration based on the rule change. Therefore, we decided that the 
Plan does not have to pay for procedure code 81456 billed for date of service March 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on October 31, 2023. 
 
You asked the Plan to pay for the home health services. You say that the claim was originally paid but then 
recouped. The Plan denied your request. The Plan says you did not supply medical records to support the 
Health Insurance Prospective Payment System (HIPPS) code billed. 
 
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. 
 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 the home health services have been 
met. In this case, the Plan recouped this claim because there were no records to support the HIPPS code billed.  
You have failed to supply medical records despite multiple requests from the Plan. Therefore, we decided that 
the Plan does not have to pay for home health services provided on October 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479 for date of service March 21, 2023. 
 
You asked the Plan to pay for procedure code 81479. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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 find that CPT code 81479 is not payable as billed. Specifically, this claim line was billed with modifier GZ. 
This means the provider expects denial due to a lack of medical necessity based on an informed knowledge of 
Medicare policy. This code is not payable as billed. Based on this information, we decided that Medicare rules 
for coverage of procedure code 81479 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 81479 for date of service March 21, 2023.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided on January 11, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that this claim was billed correctly. The Plan 
denied your request. The Plan says that the claim has missing information. 
 
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 has not provided any explanation for its denial.  The Plan 
has failed to explain what, specifically, is wrong or missing with the claim information on file.  The Plan has 
failed to cite to any rule upon which its denial was based.  The Plan has even failed to provide a copy of the 
claim that was submitted. The burden is on the Plan to show why its denial was correct.  By failing to supply 
this information, we find that the Plan has not met this burden. Therefore, we decided that the Plan has to pay 
for ambulance services provided on January 11, 2022.  
 
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 pathology services (88313, 88307, 88342) provided on 
December 13, 2022. 
 
You asked the Plan to pay for the pathology services. You say that this service was 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 K83.1 has an Excludes1 note in relation to K80.51. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the pathology services have not been met. Therefore, we decided that the Plan does not have to 
pay for pathology services (88313, 88307, 88342) provided on December 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nine units of procedure code 86255 rendered on May 11, 
2023. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no specific rationale as required by the policy as to why additional units needed to be 
performed. 
 
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 86255 is "Fluorescent noninfectious agent antibody; 
screen, each antibody." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the provider did not document 
any medically necessary reason for performing extra units in excess of the amount allowed. The records did not 
support that the additional services were reasonable and necessary 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for nine units of procedure code 86255 rendered on May 11, 2023.