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

 
We decided that the Plan does not have to pay for hospital care rendered on January 7, 2023. 
 
You asked the Plan to pay for the services. You say that the diagnosis code is consistent with the procedure 
billed. The Plan denied your request. The Plan says the diagnosis codes associated with this claim should not 
be reported together. 
 
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 99232 is not supported in the medical record, as the two diagnosis codes are not 
allowed to be billed together. Specifically, A49.8 and B95.2 are on the Excludes1 Notes Instructions. An 
exception cannot be made as the diagnosis codes are clearly related. 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 hospital care rendered on January 7, 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 meets criteria for admission. The Plan 
denied your request. The Plan says the 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 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. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint denervation (radiofrequency ablation). 
 
You asked the Plan to pre-approve sacroiliac joint denervation (radiofrequency ablation). You say that 
sacroiliac joint denervation (radiofrequency ablation) is medically necessary. The Plan denied your request. 
The Plan says the requested sacroiliac joint denervation (radiofrequency ablation) does not meet the Medicare 
LCD coverage criteria.  
 
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint denervation (radiofrequency ablation) 
is covered when the criteria listed in the Medicare rules section of this decision 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 sacroiliac joint denervation 
(radiofrequency ablation). Our reviewer says that the requested sacroiliac joint denervation (radiofrequency 
ablation) is not considered medically necessary. Our physician reviewer found that the enrollee has sacroiliac 
joint pain. The enrollee has had pain for five years and has had steroid injections. The enrollee has not completed physical therapy or home exercise programs. Radiofrequency ablation and pulsed radiofrequency for 
diagnosing or treating acute, subacute, or chronic SI joint pain are considered experimental, investigational, or 
unproven due to insufficient evidence in the peer reviewed literature.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint denervation (radiofrequency ablation) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint denervation  
(radiofrequency ablation).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on December 22, 2022. 
 
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 claim was downcoded from CPT 99285 to CPT 99283 and paid. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 documented history is not 
detailed. The medical decision making was not of high complexity. The condition was not of high severity and 
did not pose an immediate risk to life or function. As such, the billing of CPT 99285 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 emergency department services (procedure code 99285) rendered on December 22, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the Pharmacogenomics Testing. We decided that the Plan does not 
have to pay for the laboratory services.  
 
You asked the Plan to pay for the laboratory services provided on January 11, 2023, by an out-of-network 
provider.. You say that you feel you are not liable. The Plan says that there is no clinical evidence of a specific 
intent to prescribe a drug for you that has a known drug-gene interaction that requires pharmacogenetic testing 
to define safe use of that drug. The Plan states there is no record from your provider of what specific drug or 
drugs are being considered and for what indication the test performed is reasonable and necessary. The Plan 
states the claim was sent for adjustment to apply the appropriate 50 percent cost share to the enrollee. 
 
We decided that the Plan has to pay for the Pharmacogenomics Testing.  
 
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. 
 
For the Pharmacogenomics Testing it appears that the Plans contracted delegate was provided the records for 
the lab services and has failed to forward them to support the decision to deny based on not meeting Medicare 
criteria. We looked at this physician's review, the file, and Medicare rules. Therefore, we decided that the Plan 
has to pay for the Pharmacogenomics Testing.  
 
We also decided that the Plan does not have to pay for the laboratory services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50 
percent coinsurance of the Plan-allowed amount in all service settings for out-of-network services. 
 
Review of the file shows that you did receive lab services on January 11, 2023. You were asked to pay a 50 
percent coinsurance. Your 2023 EOC states enrollees must pay 50 percent of the Plan-allowed amount in all 
service settings for out-of-network services. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. We looked at this physician's review, the file, and Medicare rules. Therefore, we decided 
that the Plan does not have to pay for the laboratory services. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, abdominal aorta, real time with image 
documentation, screening study for abdominal aortic aneurysm (AAA) (76706-26) provided on January 31, 
2023. 
 
You asked the Plan to pay for the ultrasound. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the ultrasound have not been met. The date of service was billed 
with diagnosis code Z13.6 (Encounter for screening for cardiovascular disorders) which does not indicate the 
CMS criteria of a family history of abdominal aortic aneurysm, a man age 65 to 75 who has smoked at least 
100 cigarettes in his lifetime, or other risk factors recommended by the United States Preventive Services Task 
Force. Also, documentation received does not indicate that the enrollee received the screening study for one of 
the CMS risk categories of a family history of abdominal aortic aneurysm, a man age 65 to 75 who has smoked 
at least 100 cigarettes in the enrollee's lifetime, or other risk factors recommended by the United States 
Preventive Services Task Force. Therefore, we decided that the Plan does not have to pay for the ultrasound, 
abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA) 
(76706-26) provided on January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87551-59, 87563-59, 87801, 87798-
59, 87653-59, 87640-59, 87500, (87641-59 and 87481-59) provided on February 13, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the services are supported. The Plan denied 
your request. The Plan says the services are 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. 
 
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 laboratory services. Our reviewer found there is no 
documentation that fully support the above denied procedure codes. Provided records in this case do not clearly 
document testing for Mycobacteria species, Streptococcus, group B, Staphylococcus aureus, Staphylococcus 
aureus, methicillin resistant, Candida species. Also, the records do not specify the multiple organisms tested for codes 87801 and 87798. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87551-59, 87563-59, 87801, 87798-59, 87653-59, 87640-59, 
87500, (87641-59 and 87481-59) provided on February 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for seven additional units of procedure code 88341 rendered on 
January 12, 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 for why the additional units were 
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 88341 is "Immunohistochemistry or 
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in 
addition to code for primary procedure)." 
 
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 provided records in this case 
do not document any specific medical necessity for the additional stains performed. The records only state: 
"For diagnostic purposes additional studies were ordered by the attending pathologist." 
 
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 seven additional units of procedure code 88341 rendered on January 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4930 rendered on August 6, 2022. 
 
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 code is listed as invalid, not covered, bundled, not separately payable, statutorily excluded, 
not reasonable and necessary, etc. 
 
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 procedure code A4930 is not supported in the medical record. Specifically, the Medically 
Unlikely Edits (MUE) for this code is zero, which means that it is not appropriate to bill in any amount. 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 code A4930 rendered on August 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81455) provided on January 30, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the diagnosis code is appropriate and 
supported by medical records.  The Plan denied your request. The Plan says that diagnosis codes D72.829 and 
C92.00 should not be reported together  
 
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 the laboratory services. Our reviewer found the diagnosis 
code D72.829 is to signify that the enrollee white blood count is elevated, there is no excludes note that state 
C92.00 should not be coded as well. Medical records do state this enrollee has these diagnoses. Coding 81455 
with diagnosis codes D72.829 and C92.00 is acceptable. 
 
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 laboratory services have been met. Therefore, we decided that the Plan has 
to pay for the laboratory services (81455) provided on January 30, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycod/Apap Tab 5-325mg. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. 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 Oxycod/Apap Tab 5-
325mg.  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service January 10, 
2023.   
You asked the Plan to pay for procedure code 99223. You say that this should be paid for. 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 99223 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 99223 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99223 billed for date of service January 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (11055 and 11721) provided on March 
8, 2023. 
 
You asked the Plan to pay for the medical 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. 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 the medical services. Our reviewer found the medical records 
support the diagnosis used; however, the diagnosis code E08.59 cannot be sequenced first as the underlying 
condition is to be coded as principal diagnosis. 
 
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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services (11055 and 11721) provided on March 8, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cordan 80*3 tap 4mcg/cm. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. 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 Cordan 80*3 tap 4mcg/cm.  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99215 billed for date of service January 23, 
2023. 
 You asked the Plan to pay for procedure code 99215. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 99215 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 99215 
is a column II code to column I code 99223. 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 99215 billed for date of service January 23, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99231) rendered on 
February 14, 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 edit applied appropriately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 99231 is not supported in the medical record. Specifically, the claim was billed with 
two diagnosis codes (K52.9 and R19.7) that are not appropriate to bill together. An exception cannot be made, 
as the codes are related and excluded. 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 subsequent 
hospital care (procedure code 99231) rendered on February 14, 2023.