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

 
We decided that the Plan does not have to pay for inpatient hospital services provided on April 7, 2022, to 
April 10, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the diagnosis code is not supported.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with J96.01, defined as acute respiratory failure with 
hypoxia. 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 pay for the inpatient hospital services at the 
DRG originally billed. Our physician reviewer found that the enrollee was admitted to the hospital with 
increased shortness of breath and cough. He was diagnosed and treated for a respiratory infection with an 
exacerbation of COPD. The member was treated in the emergency department with improved symptoms. At 
the time of admission, the enrollee was not in respiratory distress and was not hypoxic. The enrollee did not 
require administration of oxygen at 5L/min or more, the provision of a bi-level positive airway pressure device, 
or mechanical ventilation. The documentation does not indicate that the treatment ordered by the treating 
medical providers supported the billed diagnosis code. The documentation does not consistently and 
completely support the assigned secondary diagnosis code.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on April 7, 2022, to April 10, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 15275 billed for date of service October 28, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the required information was properly 
documented. The Plan denied your request. The Plan says the documentation does not support the code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 15275 is application of skin substitute graft to face, scalp, 
eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 
100 sq cm; first 25 sq cm or less wound surface area. 
 
We find that CPT code 15275 is not supported in the medical record. Specifically, the records do not indicate 
the amount of skin graft used. 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 code 
15275 billed for date of service October 28, 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 the enrollee is medically cleared for discharge. The 
Plan denied your request. The Plan says the enrollee does not meet all the requirements. Services needed may 
be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345-GZ billed for date of service October 
31, 2022. 
 
You asked the Plan to pay for procedure code 81345-GZ. You say that this service was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this code was not submitted in 
accordance with Medicare billing guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that A/B MACs shall 
automatically deny claim line(s) items submitted with a GZ modifier. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 81345-GZ have not been met. Specifically, the records provided show that this 
code was reported with the GZ modifier.  Therefore, we decided that the Plan does not have to pay for 
procedure code 81345-GZ billed for date of service October 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from  
December 14, 2018, to December 20, 2018, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the correct DRG was billed based on the secondary diagnosis code, J18.9. The Plan 
denied your request. The Plan says the medical records do not support the DRG originally billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with the secondary diagnosis code J18.9, pneumonia, 
unspecified organism. 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 pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the medical records do not support the DRG 
originally billed. Our physician reviewer found that in this case there was no documentation of pneumonia  
during the hospitalization. The review has determined that  the documentation did not support the secondary 
diagnosis code J18.9, pneumonia, unspecified organism.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from December 14, 2018, to December 20, 2018, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 45385 and 45381 for date of service 
December 21, 2022. 
 
You asked the Plan to pay for procedure codes 45385 and 45381. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed 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. 
 
In this case, the CPT Code Manual definition of code 45385 is colonoscopy, flexible; with removal of tumor(s), 
polyp(s), or other lesion(s) by snare technique. 
The CPT Code Manual definition of code 45381 is colonoscopy, flexible; with directed submucosal 
injection(s), any substance. 
 
We find that CPT codes 45385 and 45381 are not supported in the medical record. Specifically, the operative 
report did not include documentation of a flexible colonoscopy with removal of tumor(s), polyp(s), or other 
lesion(s) by snare technique; therefore, code 45385 cannot be verified. 
 
The operative report did not include documentation of flexible colonoscopy with directed submucosal 
injection(s) for any substance. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 45385 and 45381 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 45385 and 
45381 for date of service December 21, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) U0005, 87486, 87502, 
87581, 87640, U0004, 87541, 87496, 87498, 87532, 87798(x4) and 87801(x2). We decided that the Plan does 
not have to pay for the services described by procedure code(s) 87634.  
 
You asked the Plan to pay for laboratory services provided on November 7, 2022. You say that these services 
were necessary and are supported in the medical record. The Plan says that the payment for code 87634 is 
included in the payment for code 87632. 
 
We decided that the Plan has to pay for the services described by procedure code(s) U0005, 87486, 
87502, 87581, 87640, U0004, 87541, 87496, 87498, 87532, 87798(x4) and 87801(x2).  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) U0005, 87486, 87502, 87581, 
87640, U0004, 87541, 87496, 87498, 87532, 87798(x4) and 87801(x2).  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
87634. 
 
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 87634 
is a column II code to column I code 87632. 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 the services described by procedure code(s) 87634. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 28, 2022, to 
April 2, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were billed correctly and the DRG billed should be paid. The Plan denied your request. The Plan says 
the billed diagnosis of A41.9 (sepsis, unspecified organism), is not supported by the medical record. Removal 
of this diagnosis resulted in a lower DRG being paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with a diagnosis of A41.9 (sepsis, unspecified organism). 
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 pay for the inpatient hospital services at the DRG 
originally billed. Our reviewer says that the billed diagnosis of A41.9 (sepsis, unspecified organism) is not 
supported in the medical record. Our physician reviewer found the member is a 50-year-old male with a past 
medical history including peripheral vascular disease, cardiac disease and chronic obstructive pulmonary 
disease who was admitted to the hospital with chest pain and upper extremity pain. He was diagnosed and 
treated for right toe osteomyelitis and bilateral upper extremity deep vein thrombosis. At the time of admission 
his vital signs were stable, and he was afebrile. His laboratory studies were not consistent with sepsis. There 
was no evidence of life-threatening organ dysfunction due to dysregulated host response to an infection or 
persistent hemodynamic instability. As a result, the documentation does not indicate that the treatment ordered 
by the treating medical providers supported a diagnosis code of A41.9 (Sepsis, unspecified organism).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 28, 2022, to April 2, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on January 31, 2022, billed with 
code 95822-26-XU. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95822-26-XU is Electroencephalogram (EEG); recording 
in coma or sleep only 

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 imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that recording in coma or sleep would be 
reported for routine electroencephalogram and would not be reported for neuromonitoring services for surgical 
lumbar procedures. There is a more appropriate code to report for service provided. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on January 31, 2022, billed with code 95822-26-
XU.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 80053 and 85025. We decided that the Plan does not 
have to pay for procedure codes 82378 and 82962.  
 
You asked the Plan to pay for lab services (80053, 85025, 82378, 82962) provided on August 24, 2022.. You 
say that these services were medically necessary. The Plan says that the documentation does not support the 
billed services. 
 We decided that the Plan has to pay for procedure codes 80053 and 85025.  
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
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 pay for procedure codes 80053 and 85025. Our 
reviewer says that the documentation supports codes 80053 and 85025. The records included lab results for 
these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 80053 and 85025 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 80053 and 85025.  
 
We also decided that the Plan does not have to pay for procedure codes 82378 and 82962. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
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 pay for procedure codes 82378 and 82962. Our 
reviewer says that codes 82378 and 82962 are not supported by the records. Our physician reviewer found that 
records do not show that a separate glucose test was performed.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 82378 and 82962 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 82378 and 82962. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid swing and stance phase control (L5828), stance 
flexion feature (L5845), fluid stance extension (L5848), microprocessor control feature (L5856). 
 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 the items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that physician documentation does not support why the enrollee would need a microprocessor knee over a mechanical knee. The enrollee's activities and function can be safely and effectively met with a mechanical 
K3 knee. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a fluid swing and stance phase control (L5828), stance flexion feature (L5845), fluid stance 
extension (L5848), microprocessor control feature (L5856).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 16, 2021, 
to November 19, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services were billed correctly. The Plan denied your request. The Plan says the medical records do not support 
the billed principal diagnosis of A41.9 (sepsis, unspecified organism) and secondary diagnosis of R65.20 
(severe sepsis without septic shock). As a result, a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with a principal diagnosis of A41.9 (sepsis, unspecified 
organism) and a secondary diagnosis of R65.20 (severe sepsis without septic shock). 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 pay for the inpatient hospital services at the DRG originally billed. Our 
reviewer says that the billed principal diagnosis of A41.9 (sepsis, unspecified organism) and secondary 
diagnosis of R65.20 (severe sepsis without septic shock) are not supported by the medical record. Our 
physician reviewer found the member is an 88-year-old male with a past medical history including diabetes 
mellitus, hypertension, chronic obstructive pulmonary disease and chronic kidney disease who presented to the 
hospital with increased shortness of breath with distress. He was diagnosed and treated for pneumonia, 
rhinovirus infection with a chronic obstructive pulmonary disease exacerbation and a urinary tract infection. At 
the time of admission, the member's symptoms were improved, and he was afebrile. The laboratory studies 
were not consistent with sepsis. There was no evidence of life-threatening organ dysfunction due to 
dysregulated host response to an infection or persistent hemodynamic instability.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 16, 2021, to November 19, 2021, at the Diagnosis 
Related Group (DRG) originally billed.