Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 62322 rendered on May 8, 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 Current Procedural Terminology (CPT) code 62322-59 remains not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services. Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found that per the 
documentation from the anesthesiologist, the documentation supports a 62322 with a 59 modifier. Coding 
policy allows the 59 modifier to be used with CPT 62322 when the enrollee receives general anesthesia. CPT 
62322 was done for post-operative pain. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
procedure code 62322 rendered on May 8, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 9, 2023, billed with 
codes 87481, 87491, 87653, 87640, 87798, 87641, and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that the coding is approved by Medicare. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This NGS panel was not billed with a single code as required. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 9, 2023, 
billed with codes 87481, 87491, 87653, 87640, 87798, 87641, and 87500.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223, 99232) provided on May 10, 2023, and 
May 11, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed 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, the CPT Code Manual definition of code 99223 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded" The CPT Code Manual definition of code 99232 is 
"Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision 
making. When using total time on the date of the encounter for code selection, 35 minutes must be met or 
exceeded". 
 
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 use of codes 99223 
and 99232 is not supported by the records provided. Our reviewer found that there was no documentation of 
medical decision-making of high complexity and documentation of 75 minutes of time met or exceeded for 
May 10, 2023. There was no moderate level of medical decision-making for May 11, 2023. 
 
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 the services (99223, 99232) provided on May 10, 2023, and May 11, 2023.
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. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH. 
 
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 patient appears to be responding to current treatment but is still somewhat 
unstable and requires additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for transfer. There are no services at the LTACH that the patient requires that are not 
already available and covered at the current facility. Our reviewer also found that transfer to the LTACH is not 
medically necessary as the patient is not yet stable for transfer and it would not be clinically advantageous at 
this time. Completion of treatment at the current facility is recommended.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing panel billed with procedure codes 87801, 87798, 
and 87493 for date of service March 23, 2023. 
 
You asked the Plan to pay for the testing panel. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that panels must not be unbundled and submitted as 
one unit of service. 
 
We looked at the file and Medicare rules. Review of the file shows that the panel provided was not billed with 
one unit of service. This means this service was billed as unbundled. Based on this information, we decided 
that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the testing panel billed with procedure codes 87801, 87798, and 87493 for date of 
service March 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve that Intracept procedure. 
 
You asked the Plan to pre-approve Intracept. You say that the procedure is needed to alleviate the enrollee's 
chronic lower back pain. The Plan denied your request. The Plan says that the request 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no magnetic resonance imaging (MRI) showing only modic changes without facet 
degenerative joint disease or foraminal stenosis. The cause of pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve that Intracept procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that these services are medically necessary for 
the enrollee. The Plan denied your request. The Plan says these services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for the enrollees condition beyond what was approved by the health plan. The records do 
not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide 
treatment, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The enrollee has had extensive prior therapy and has had instruction in a home 
exercise program. The enrollee does not require ongoing skilled therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87801 (x3), 87481, 87653 and 87798 billed 
for date of service January 24, 2023. 
 You asked the Plan to pay for procedure codes 87801 (x3), 87481, 87653 and 87798. You say that these 
services were necessary and are supported in the medical record. The Plan denied your request. The Plan says 
these codes are not supported 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, we have confirmed that codes 87481, 87653 and 87798 are column II codes to column I code 
87801; however, 87481, 87653 and 87798 were each billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87801 (x3), 87481, 87653 and 87798. Our 
reviewer says that these codes are not supported as billed. Our reviewer found that three units of code 87801 
are not supported, as this procedure code includes "multiple organisms" and only 1 unit of service should be 
billed for this procedure. In addition, modifier XU is not supported with codes 87481, 87653 and 87798. The 
laboratory report does not include sufficient documentation to support rationale for separate billing of these 
codes. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87801 (x3), 87481, 87653 and 87798 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87801 (x3), 87481, 87653 and 
87798 billed for date of service January 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers 60 one-way transportation trips when each one-way trip does not exceed 50 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ProstateNow Hereditary Prostate Cancer Extended Panel 
billed with code 81162 for date of service March 18, 2022. 
 
You asked the Plan to pay for ProstateNow Hereditary Prostate Cancer Extended Panel. You say that this 
testing was medically necessary and reasonable. The Plan denied your request. The Plan says the code billed 
does not adequately describe the panel provided. 
 
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 81162 is BRCA1 (BRCA1, DNA repair associated), 
BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full 
sequence analysis and full duplication/deletion analysis (i.e., detection of large gene rearrangements). 
 We find that CPT code 81162 is not supported in the medical record. Specifically, the code used to report this 
panel is not a panel code and does not include all of the genes tested in this case. Another code would be more 
appropriate to report the full panel provided. Based on this information, we decided that Medicare rules for 
coverage of ProstateNow Hereditary Prostate Cancer Extended Panel have not been met. Therefore, we decided 
that the Plan does not have to pay for ProstateNow Hereditary Prostate Cancer Extended Panel billed with code 
81162 for date of service March 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (G0151 x8). 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. 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 services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee is 
ambulating 150 feet with standby assistance without an assistive device. The enrollee is modified independent 
with bed mobility and performing transfers. The enrollee is back to her baseline level of mobility or very close 
to it. The enrollee has 4/5 motor strength in the lower extremities. The enrollee may require some level of 
supervision or assistance, but this does not require the services of skilled physical therapist. The enrollee can 
continue with a home exercise program to increase endurance. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy (G0151 x8).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the services (95816) provided on April 11, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code is 
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 95816 is "Electroencephalogram (EEG); including recording awake and drowsy". 
 
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 use of code 95816 is 
supported by the records provided. Our reviewer found that the code description states that recording while 
drowsy is included, not that it is a required component of this code. CPT Assistant released guidance in 
September 2023 that clarifies that drowsy recording is not required for 95816. Although it was not in effect for 
the DOS in question, this shows the intent for the code description, that drowsy recording is included but not 
required. 
 
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 
the services (95816) provided on April 11, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (97760, 29530) provided on December 1, 2017. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed 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. 
 
In this case, the CPT Code Manual definition of code 97760 is Orthotic(s) management and training 
(including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) 
and/or trunk, initial orthotic(s) encounter, each 15 minutes. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 97760 is 
not supported by the records provided. Our reviewer found that the record does not contain documentation 
stating that orthotic management and treatment was performed for 15 minutes. 
 
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 97760 have not been met. 
 
In this case, we have also confirmed that code 29530 is a column II code to column I code 97760. 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 
(97760, 29530) provided on December 1, 2017.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of procedure codes 98561, 95938, and 95939 
rendered on March 17, 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 is no medically necessary reason for performing extra units. 
 
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 95861: 
 
Needle electromyography; 2 extremities with or without related paraspinal areas  
CPT 95938: 
 
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 
recording from the central nervous system; in upper and lower limbs 
 
CPT 95939: 
 
Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs 
 
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 in this case, the electromyography 
(EMG) was only done of two extremities. In as much there would not have been an indication for the use of 
more than one unit of 95861, which reflects EMG monitoring in 2 extremities. Likewise for CPT codes 95838 
and 95939 these are services that are more "global" in nature (for lack of a better term) covering all of the 
extremities monitored. There is not a need for a submission of additional units on a claim for these specific 
procedure codes. 
 
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 additional units of procedure codes 98561, 95938, and 95939 rendered on March 17, 2023.