Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 93308, 93321, and 93325 performed on date of service 
February 28, 2023. 
 
You asked the Plan to pay for 93308, 93321, and 93325. You say that codes 93308, 93321, and 93325 should 
be covered as billed because they are supported in the medical records. The Plan denied your request. The Plan 
says that payment for codes 93308, 93321, and 93325 is bundled into payment for code 33361, billed on the 
same date of service. 
 
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 case file did not include proof that code 33361 was billed for date of service 
February 28, 2023, by the same provider who performed codes 93308, 93321, and 93325. Without 
documentation showing 33361 was billed by the same provider for the same date of service, we cannot confirm 
whether the Plans rationale was correct in denying 93308, 93321, and 93325. Therefore, we decided that the 
Plan has to pay for procedure codes 93308, 93321, and 93325 performed on date of service 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 17, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you have been an established patient with this 
provider for over three years working with her for your past abusive relationship (divorce) and you do not want 
to switch providers. The Plan denied your request. The Plan says a licensed mental health counselor is not 
eligible to enroll in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychotherapy provided on May 17, 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 would benefit from acute inpatient 
rehab. The enrollee's goals are to increase strength, endurance, and independence and discharge home. The 
enrollee is willing and able to participate in 15 hours of therapy, over the course of 7 days a week. The Plan 
denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not 
meet the requirements for approval. 
 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 an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 23, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88323, 88341 and 88342 billed for date of 
service February 7, 2022. 
 You asked the Plan to pay for procedure code(s) 88323, 88341 and 88342. You say that your organization is 
not affiliated with the hospital, so you should get separate payment for these services. The Plan denied your 
request. The Plan says these codes are included in the facility payment and are 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 facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88323, 88341 and 
88342. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88323, 
88341 and 88342. Based on this information, we decided that Medicare rules for coverage of procedure code 
88323, 88341 and 88342 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88323, 88341 and 88342 billed for date of service February 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rectal sensor. 
 
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no clinical documentation that provides clinical justification for the medical 
necessity of this request. 
 
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 sensor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a medical history of ulcerative colitis requiring ileal pouch anastomosis and reversal 
ileostomy. The enrollee is also noted to have urinary retention. There is limited clinical documentation 
regarding an evaluation of the enrollees ulcerative colitis and fecal incontinence and he was primarily evaluated for allergies and anxiety/depression on 8/16/2023. More clinical information from an appropriate 
provider, including gastroenterology or urology, is required to assess if the requested rectal stimulator is 
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 the sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a rectal sensor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes Q0092 and R0070 rendered on May 22, 
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 denied codes remain 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 the denied codes is: 
 
Healthcare Common Procedure Coding System (HCPCS) Q0092: 
 
Set-up portable x-ray equipment  
HCPCS R0070: 
 
Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or 
location, one patient seen 
 
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 language of the report of the 
single view chest x-ray of 5/22/23 does not support the use of portable technique. 
 
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 Q0092 and R0070 rendered on May 22, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service April 25, 
2023. 
 You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 36556. 
 
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 36556. 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 April 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87502 billed for date of service December 
12, 2022. 
 You asked the Plan to pay for procedure code 87502. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 87502 is bundled into payment for code 87633. 
 
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 87502 
is a column II code to column I code 87633. 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 87502 billed for date of service December 12, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 23, 2022. 
 
You asked the Plan to pay for the medical services. You say that your doctor provided this service, so this 
claim should be paid. 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 D46.9 has an Excludes1 note in relation to D64.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical services have not been met. Therefore, we decided that the Plan does not have to pay for 
medical services provided on November 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 an Inpatient Rehabilitation Facility is 
needed. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are 
requesting do not meet the requirements for approval. 
 
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 an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on May 1, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on May 1, 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 have zero mobility to get out of bed and that you 
have been laid up in bed since August 23, 2023, through the whole time as an inpatient. You need help with 
physical therapy to regain strength in your legs to at least be able to get to the bathroom with aid. The Plan 
denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not 
meet the requirements for approval. 
 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 an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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 pay for procedure code 99233 billed for March 2, 2023. 
 
You asked the Plan to pay for procedure code 99233. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99233 is bundled into payment for code 99223. 
 
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 99233 
is a column II code to column I code 99223 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 99233 billed for March 2, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure at L3-S1. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that there is no magnetic resonance 
imaging showing only modic changes without facet joint disease or foramial stenosis. The cause of pain is also 
unclear. The Plan denied your request. The Plan says medical studies have not proven this surgery is helpful for 
the treatment of the enrollee's health issue. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
joint disease or foramial stenosis. The cause of pain is also unclear.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure at L3-S1.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 30140 billed for November 3, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 30140 is 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 30140 is submucous resection inferior turbinate, partial 
or complete, any method. 
 
We find that CPT code 30140 is not supported in the medical record. Specifically, there is no documentation of 
a partial or complete submucous resection of the inferior turbinate using any method. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 30140 billed for November 3, 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 you want to return to being independent and that you 
are eager to participate in the 3 hours of aggressive rehab that an acute rehab hospital will offer. The Plan 
denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not 
meet the requirements for approval. 
 
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 an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87798 billed for date of service 
November 4, 2022.  
 
You asked the Plan to pay for procedure codes 87481 and 87798. 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 87481 is 6. The MAI value for this code is 3. You billed 7 units of this 
code, exceeding the MUE. The MUE value for CPT code 87798 is 13. You billed 18 units of this code. 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 87481 and 87798 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 87481 and 87798 billed for date of service November 4, 2022.