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

 
We decided that the Plan does not have to pay for procedure codes 99309 and 99316 billed for dates of service 
from August 3, 2022, to August 26, 2022. 
 
You asked the Plan to pay for procedure codes 99309 and 99316. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says the provided 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 code 99309 is: Subsequent nursing facility care, per day, for 
the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has 
developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the 
bedside and on the patient's facility floor or unit. 
 
The definition of code 99316 is: Nursing facility discharge day management; more than 30 minutes. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 99309 and 99316. Our reviewer says that 
procedure codes 99309 and 99316 do not meet criteria for payment. Our reviewer found that the provided 
medical records do not document that there was a detailed history or detailed examination to warrant reporting 
of code 99309. Additionally, there was no documentation of the amount of time spent by which to verify code 
99316. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99309 and 99316 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99309 and 99316 billed for dates of service from August 
3, 2022, to August 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness, and electronic 
connection device for a power mobility device. 
 
You asked the Plan to pre-approve expandable controller, harness, and electronic connection device. You say 
that you need these to make your daily life better. The Plan denied your request. The Plan says these 
components are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve expandable controller, harness, and 
electronic connection device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have use of your upper extremities 
and can operate and control the power options using the switches included int he base wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of expandable controller, harness, and electronic connection device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, and 
electronic connection device for a power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2310).  
 
You asked the Plan to pre-approve an electronic connection device. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the requested item 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 an electronic connection device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee does have use of the upper extremities and can operate and 
control the power options using the switches that are included in the basic wheelchair. 
 
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 electronic connection device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electronic connection device (E2310).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44160-58 billed for date of service 
November 20, 2022. 
 
You asked the Plan to pay for procedure code 44160-58. You say that these services were reported correctly 
and are supported in the provided documentation. The Plan denied your request. The Plan says this service is 
not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 44160-58. Our reviewer says that this service 
is not supported for payment. Our reviewer found the operative report does not include documentation to 
support Partial colectomy, with removal of terminal ileum with ileocolostomy. Per the report, "we elected to 
leave the patient discontinuity rather than creating an ostomy or ileocolic anastomosis". In this case, this 
procedure code cannot be verified in the medical record submitted. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 44160-58 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 44160-58 billed for date of service November 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy (97026) provided on September 13, 2022. 
 
You asked the Plan to pay for infrared therapy. You say that you disagree with the denial and request this claim 
is reprocessed correctly. The Plan denied your request. The Plan says infrared therapy is considered not 
reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infrared therapy have not been met. Specifically, Medicare guidelines confirm that there is 
sufficient evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable 
and necessary. Therefore, we decided that the Plan does not have to pay for infrared therapy (97026) provided 
on September 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  hospital discharge day management; more than 30 minutes 
(99239) provided on August 31, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation submitted does not include a hospital discharge day management note with a 
recorded duration of time of 31 minutes or more for the billed date of service of August 31, 2022; therefore, the 
billed service cannot be verified.  
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
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 service. Our reviewer found Current Procedural 
Terminology (CPT) code 99239 (1 unit) was not supported. The documentation submitted did not include a 
hospital discharge day management note with a recorded duration of time of 31 minutes or more for the billed 
date of service of August 31, 2022; therefore, the billed service cannot be verified. It is noted that multiple 
attempts were made to contact the provider for additional information. The review has determined that the 
documentation did not support procedure code 99239 provided on August 31, 2022.  
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for  hospital discharge day management; more than 30 minutes (99239) provided on August 31, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the addition, endoskeletal system, below knee, flexible 
protective outer surface covering system (L5962). 
 
You asked the Plan to pre-approve an extra advanced prosthetic cover. You say that the records provided 
support the necessity of the service in dispute. The Plan denied your request. The Plan says the standard 
prosthetic cover has already been approved.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an extra advanced prosthetic cover have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the addition, endoskeletal system, below knee, flexible protective outer surface covering 
system (L5962).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness, and expandable controller. You say that 
these items are medically necessary. The Plan denied your request. The Plan says there is not a medical need to 
control these power options through the joystick. 
 
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 electronic connection, harness, and 
expandable controller. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the requested electrical accessories are not medically 
necessary as the enrollee has use of the upper extremities and can operate and control the power options using 
the switches that are included in the basic wheelchair. 
 
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 electronic connection, harness, and expandable controller have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), harness 
(E2313), and expandable controller (E2377).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found continuation of a home 
ventilator is not medically necessary. If this enrollee has chronic carbon dioxide (CO2) retention related to 
obesity hypoventilation syndrome, the enrollee may benefit from bilevel positive airway pressure (BiPAP) 
during sleep as an outpatient. Medicare does not cover a home ventilator in the treatment of obesity 
hypoventilation syndrome, or when used at settings that can be provided with BiPAP. Of note, the plan has 
approved the home ventilator for an additional 3 months, which allows time for transition to BiPAP. 
 
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 ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0402, G0463, and G0404 billed for date of 
service November 4, 2022. 

You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says a condition code 
was not reported. 
 
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 the evaluation and management CPT codes G0402 and G0463 were not billed with an applicable 
condition code. We find that code G0404 may be payable once the errors for G0402 and G0463 are corrected. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes G0402, G0463, and G0404 
billed for date of service November 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service February 7, 
2023. 
 
You asked the Plan to pay for procedure code 81345. You say that the claim should be paid. 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 February 7, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental healthcare after June 28, 
2023. 
 
You asked the Plan to pre-approve continued inpatient mental healthcare. You say that the enrollee is still 
showing signs of anxiety, negative thought process, paranoia, and depression. The Plan denied your request. 
The Plan says the enrollee no longer requires inpatient care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient mental healthcare. 
Our reviewer says that continued inpatient care is not medically necessary. Our physician reviewer found there 
is no indication in medical records that the enrollee's psychiatric symptoms cannot be managed on a less 
restrictive basis after the last approved date. The enrollee has no acute psychiatric issues that would require 
continued inpatient care. As of the last covered day, the enrollee did not express any active suicidal ideation or 
any intent to harm herself or others.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient mental healthcare have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient mental healthcare after June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder with bracket for a power wheelchair. 
 
You asked the Plan to pre-approve cup holder. You say that you are appealing this denial. The Plan denied your 
request. The Plan says a cup holder is not primarily medical in nature so is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a cup holder with bracket for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
November 21, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that the claim should be paid. The 
Plan denied your request. The Plan says payment for codes 87481 and 87653 are bundled into payment for 
code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87481 and 87653 are a column II code to column I code 87801. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for 
date of service November 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (20700, 15271, 15272 and 13160) 
provided on January 24, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Review of the available clinical case notes and records presented for an 
appeal of coverage of assistant surgeon services for Current Procedural Terminology (CPT)13160, has been 
completed. Code 13160 has a status indicator of 1 which does not allow for assistant surgeon payment. The 
information received does meet guidelines and the denial is upheld. As the CPT code 20700 was billed an 
appropriate primary code that is not eligible for payment to the same practitioner for the same patient on the 
same date of service; we find that Medicare rule for payment for CPT code 20700 has not been met. Based on 
this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical services (20700, 15271, 15272 and 13160) provided 
on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653 and 87641 billed for 
date of service November 8, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87653 and 87641. You say that these services 
were necessary and are supported as billed. The Plan denied your request. The Plan says these services are not 
supported for separate payment. 
 
 
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 87150, 87481, 87653 and 87641 is a column II code to column I code 
87801 and/or 87500; however, 87150, 87481, 87653 and 87641 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87150, 87481, 87653 and 87641. Our 
reviewer says that these services are not supported for separate billing/reporting. Our reviewer found the 
laboratory report does not include documentation to support modifier XU (unusual non-over lapping service) 
for any of the codes at issue. Therefore, these procedures denied correctly as unbundled services. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87653 and 87641 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 87150, 87481, 87653 and 87641 billed for 
date of service November 8, 2022.