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

 
We decided that the Plan does not have to pay for the surgical assistant services provided on September 20, 
2022, billed with codes 22830, 63047, and 22614. 
 You asked the Plan to pay for the services as billed. You say that all billed codes should be paid in full. The 
Plan denied your request. The Plan says the denied codes 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, we have confirmed that codes 22830 and 63047 are column II code in relation to column I code 
22633; however, these codes were billed with a modifier.  
 
In addition, the CPT code definition of code 22614 is arthrodesis, posterior or posterolateral technique, single 
interspace; each additional interspace (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 as billed. Our reviewer says that the billed codes 
are not supported as separately payable. Our reviewer found the procedure report includes documentation of a 
laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root(s), (spina or lateral recess stenosis), for a single vertebral lumbar segment, and billed 
with modifier -59 distinct procedural service, however, CPT 22633 includes laminectomy and/or 
discectomy. Th procedure report does include documentation to support modifier -59 distinct procedural 
service. An exploration of spinal fusion is also documented in the operative report and billed with modifier -59 
for distinct procedural service; however, this procedure would be included in arthrodesis procedure performed.  
 
Regarding code 22614, the operative report describes a primary arthrodesis procedure performed, which 
includes up to 6 vertebral segments. Therefore, billing this additional segment cannot be verified. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical assistant services provided on September 20, 2022, billed with codes 
22830, 63047, and 22614.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 23474-58-LT billed for date of service December 15, 
2021. 
 
You asked the Plan to pay for code 23474-58-LT. You say that this service was medically necessary and the 
medical records support payment. The Plan denied your request. The Plan says code 23474-58-LT 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. 
 
In this case, the CPT Code Manual definition of code 23474-58-LT is revision of total shoulder arthroplasty, 
including allograft when performed; humeral and glenoid component 
 
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 code 23474-58-LT. Our reviewer says that code 23474-58-
LT is not supported in the medical record. Our reviewer found the operative report does not include enough 
documentation to confirm a revision of total shoulder arthroplasty, per NCCI Policy "The physician may access 
the shoulder joint through the previous incision. Muscles are reflected and the joint capsule is incised. Any scar tissue is removed. The physician manually dislocates the shoulder. Cement is removed from around the glenoid 
component with a motorized or hand instrument and the component is removed. Once prepared properly, the 
glenoid vault is filled with polymethylmethacrylate (bone cement) and the new glenoid component is pushed 
into place and held until the cement cures. The physician removes scar tissue and cement from around the 
humeral component with chisels and gouges. The humeral component is removed from its bed. The physician 
reconstructs the humerus with instrumentation and/or bone graft. A new humeral component is inserted". The 
procedure report documents "The tray and the polyethylene were then removed from the proximal humerus...I 
proceeded with the revision reverse shoulder arthroplasty. The previous placed glenosphere was then 
removed...A 36mm lateralized glenosphere was then placed and impacted and screwed into place. I then trailed 
different options for the humeral tray and polyethylene and found the appropriate size with stability of the 
shoulder. The trial plates were then removed, and the final implants were then placed. The shoulder was then 
once again reduced, and I was able to confirm good stability of the shoulder as well as good range of motion 
without any evidence of impingement." CPT 23474 cannot be verified, as the procedure report has insufficient 
documentation to support procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 23474-58-LT have not been met. Therefore, we decided that the Plan does 
not have to pay for code 23474-58-LT billed for date of service December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service December 3, 
2022 to December 31, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the services were necessary. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service December 3, 2022 to December 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary to 
provide the services needed for the enrollee's care. The Plan denied your request. The Plan says the enrollee's 
medical needs can be met in the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 22, 2022, 
to March 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the services were billed 
correctly. The Plan denied your request. The Plan says the final home health claim in dispute was not billed 
with the appropriate corresponding admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 22, 2022, to 
March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99214 billed for date of service September 14, 2022. 
 
You asked the Plan to pay for code 99214. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 99214 is not supported in the medical records because the records 
don't support a moderate level of decision making or the time required of the code 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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient which requires a medically appropriate history and/or examination 
and moderate level of decision making. When using time for code selection, 30-39 minutes of total time is 
spent on the date of the encounter. 
 
 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 code 99214. Our reviewer says that code 99214 is not 
supported in the medical record. Our reviewer found CPT code 99214 requires 2 out of 3 of the following: a 
detailed history, a detailed examination and medical decision making of moderate complexity. A detailed 
history requires a chief complaint, an extended history of present illness, a pertinent review of systems and 
pertinent past, family and social history. A detailed examination requires an extended examination of the 
affected body area(s) or organ system(s) and other symptomatic or related organ systems(s). Medical decision 
making of moderate complexity requires 2 out of 3 of multiple diagnoses or management options, a moderate 
amount and complexity of data reviewed and moderate risk of complication. Provided records in this case do 
not document a chief complaint, an extended history of present illness, a pertinent review of systems and 
pertinent past, family and social history. Provided records in this case do not document an extended 
examination of the affected body area(s) or organ system(s) and other symptomatic or related organ systems(s). 
Provided records in this case do not document 2 out of 3 of multiple diagnoses or management options, a 
moderate amount and complexity of data reviewed and moderate risk of complication.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99214 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99214 billed for date of service September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87481, 87653, 87798 and 87801) 
provided on October 23, 2022. 
 You asked the Plan to pay for the laboratory services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says the payment for these services is 
included in the payment for other services provided on this same date. 
 
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 laboratory services. Our physician 
reviewer found for code 87798, the documentation submitted was reviewed and does not meet criteria. The 
laboratory report documents 17 infectious agents tested. Two (2) units are verified; however, were not reported 
with modifier and therefore, was denied. For this procedure code, 12 units were billed; however, there is 
insufficient documentation to confirm which infectious agents billed under this procedure code to verify correct 
units billed. For code 87801, the documentation submitted was reviewed and does not meet criteria. The 
laboratory report documents 17 infectious agents tested. Two units are verified; however, were not reported 
with modifier and therefore, was denied. For this procedure code, three (3) units were billed; however, there is 
insufficient documentation to confirm which infectious agents billed under this procedure code to verify correct 
units billed. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87481, 87653, 87798 and 87801) provided on October 23, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the observation discharge services provided on December 7, 2022. 
 
You asked the Plan to pay for the observation discharge services. You say that the enrollee was admitted to 
observation and was discharged by the provider. As such, this service should be paid. The Plan denied your 
request. The Plan says that this service was denied because the related of qualifying service was not paid. 
 
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 Plan has failed to provide a valid denial rationale in this case. The claim was 
denied indicating that a related or qualifying service was not paid, but no explanation is given to support this. 
The records show that the enrollee was admitted to observation status and was discharged on the date of service 
at issue. Without a clear rationale, we find that the denial of payment is not substantiated. Therefore, we 
decided that the Plan has to pay for the observation discharge services provided on December 7, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: 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 services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary for the enrollee. 
 
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 treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vertiflex interspinous spacer provided on March 11, 
2022. 
 
You asked the Plan to pay for the Vertiflex interspinous spacer. You say that the Vertiflex interspinous spacer 
was recommended for the patient's lumbar spinal stenosis after conservative measures failed to provide 
sustainable relief. The Plan denied your request. The Plan says this service is not medically necessary as this 
procedure has not been shown to be safe and effective in long-term studies 
 
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 pay for the Vertiflex interspinous spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex interspinous spacer is considered experimental at this time.  More research is needed before this device can be considered medically necessary and reasonable. 
 
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 Vertiflex interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pay for the Vertiflex interspinous spacer provided on March 11, 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 member requires the rehabilitation care provided 
only in an IRF. The Plan denied your request. The Plan says the member's needs can be met at 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 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 or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 lab services (81479) provided on December 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on 
December 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to regain function. The Plan denied your request. The Plan says the enrollee can safely receive this 
care in another setting, 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.