Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 rendered on March 15, 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 this is not separately reportable. 
 
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 36000 is "Introduction of needle or intracatheter, vein." 
 
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 medical record describes an 
emergency department visit with IV therapy. CPT 36000 may be reported alone if the only service provided is the introduction of the needle into a vein.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 36000 rendered on March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedures codes 88341 and 88342 rendered on March 22, 
2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim needs to be resubmitted with modifier -59. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is:  
CPT 88341: 
 
Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain 
procedure (List separately in addition to code for primary procedure) 
 
CPT 88342: 
 
Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain 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 documentation describes that 
these procedure codes were reported on the same date of service as another service which includes this 
procedure. In this case, an appropriate modifier should be appended. 
 
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 procedures codes 88341 and 88342 rendered on March 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirements for 
admission to an IRF.  
 
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.  There are no 
complex nursing or rehabilitation needs. 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 therapy 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 waive the copayment for an office visit on June 22, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you feel that you shouldn't have to 
pay based on the benefit quoted. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 a $50 
copayment per visit for a specialist. Covered services include medically necessary medical care or surgery 
services furnished in a physicians office, certified ambulatory surgical center, hospital outpatient department, 
or any other location. Consultation, diagnosis, and treatment by a specialist. The provider billed in the amount 
of $120 and the allowed amount is $27.03. This is less than the copayment amount. Therefore, results in the 
total cost sharing amount of $27.03. You have been asked to pay a $27.03 copayment, which is less than the copayment for an office visit. This 
item/service falls within the physician/practitioner services, including doctors office visits benefit category. 
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. Therefore, we decided that 
the Plan does not have to waive the copayment for an office visit on June 22, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services rendered from April 1, 2016, to 
April 25, 2016. 
 
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 that the speech therapy services were not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 supported by the medical records. Our reviewer found the records show that at least 720 minutes 
of therapy, from two different disciplines, was provided during this period. There were at least five days of one 
therapy, and at least three days of a second therapy. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
skilled nursing facility (SNF) services rendered from April 1, 2016, to April 25, 2016.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88381 billed for date of service March 10, 
2023.  
 
You asked the Plan to pay for procedure code 88381. You say that the services were medically necessary.  The 
Plan denied your request. The Plan says the billed number of units are not supported by the records as both 
provided and medically necessary.  
 
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 88381 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE.  
 
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 88381. Our reviewer says that the services at 
issue in this case do not meet the criteria for coverage. Our reviewer found there is no documentation to 
support code 88381.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 88381 billed for date of service March 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 24, 2023, 
to April 30, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the medical records provided support 
that the services in dispute were medically necessary. The Plan denied your request. The Plan says this acute 
inpatient admission was not medically necessary. The Plan says that the enrollee did not have to be admitted. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department with confusion, aggression, 
agitation, and repeating her concern for theft of her property. Psychiatry suggested that the symptoms were 
likely due to her underlying cognitive impairment (delirium in the setting of dementia) and non-compliance 
with medication. The plan included restraints, discontinuing bupropion, addition of Zyprexa and Seroquel, but 
continuing (restarting) other medications including Citalopram, Trazodone. The enrollee's vitals remained 
stable. Based on the chronic nature of the enrollee's condition, stability hemodynamically, and only need for 
medication adjustments and restarting of medications already prescribed for outpatient use, it was not expected 
that they would have required hospital services that would have likely crossed 2 midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on April 24, 2023, to April 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653, and 87798 rendered on 
January 25, 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 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.  
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 laboratory report does not 
include documentation to support the rationale of using the modifier for unusual non-overlapping services. The 
denied codes and modifier XU 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 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 87481, 87653, and 87798 rendered on January 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 28, 
2023. 
 You asked the Plan to pay for procedure code 70450. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service April 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing, 22 or more drug class(es) (G0483) provided 
April 25, 2023. 
 You asked the Plan to pay for the drug testing. 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. 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Code G0483 (1 Unit) remains not 
supported. The submitted medical records do not contain sufficient detail to support the billed charges. The 
medical records submitted do not include an order that specifically list what test(s) are to be performed in the 
custom panel. Based on this information, we decided that Medicare rules for coverage of the drug testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the drug testing, 22 or more drug 
class(es) (G0483) provided April 25, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 93622, 93623, 93653, 93662 rendered on March 27, 
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 that the 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 
the denied codes is: 
 
CPT 93622: 
 
Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode 
catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List 
separately in addition to code for primary procedure) 
 
CPT 93623: 
 
Programmed stimulation and pacing after intravenous drug infusion (List separately in addition to code for 
primary procedure) 
 
CPT 93653: 
 
Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, 
induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation 
of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular 
pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle 
recording, when performed; with treatment of supraventricular tachycardia by ablation of fast or slow 
atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial 
focus or source of atrial re-entry 
 
CPT 93662: 
 
Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and 
interpretation (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 supported by the medical records. Our reviewer found that the enrollee presented with a cardiac 
arrhythmia found to be atrial flutter, and had ablation and loop implant. The procedure note supports that the 
denied codes were supported and rendered in this case.  
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 been met. Therefore, we decided that the Plan has to pay for 
procedure codes 93622, 93623, 93653, 93662 rendered on March 27, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 2, 2022, to 
February 4, 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 medical records support a decision to reprice this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that there are no records identified 
for review during this time period. Therefore, the services 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 have not been met. Therefore, we decided that the Plan does not 
have to pay for home health services provided from February 2, 2022, to February 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits (G0299).  
 You asked the Plan to pre-approve home health skilled nursing visits . You say that you are a severe diabetic, 
blind, and need the home health services. You also say that you live alone and need extra help. The Plan denied 
your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health skilled nursing visits. Our 
reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found the 
enrollee does not have documented skilled nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve home health skilled nursing visits (G0299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Surtentec Vimax allograft (20930). 
 
You asked the Plan to pre-approve Surtentec Vimax allograft. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Surtentec Vimax allograft. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested SurGenTec 
Vimax allograft is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Surtentec Vimax allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Surtentec Vimax allograft (20930).