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

 
We decided that the Plan does not have to pay for outpatient hospital services billed for date of service April 
25, 2023. 
 
You asked the Plan to pay for outpatient hospital services. You say these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says there are one or more I/OCE edit 
errors on this claim which must be corrected before payment may be made. 
 
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 when an inpatient only 
procedure is reported on an outpatient claim, edit 18 is invoked. The inpatient procedure and all other services 
performed on the same date are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of outpatient hospital services have not been met. Specifically, code 23474 is listed as an inpatient 
only procedure and has a status indicator of C. This service is not on the separate procedure list. This code 
was billed for date of service April 25, 2023. Therefore, code 23474 is denied, and any other lines billed with 
date of service April 25, 2023, are denied as well. Therefore, we decided that the Plan does not have to pay for 
outpatient hospital services billed for date of service April 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you cannot stand, bathe, or do any forms of 
movement. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
April 5, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on April 5, 2023, and billed with codes 87150, 87481, 87641, 87653, 87798, and 87801.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99284) rendered 
on June 29, 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 CPT 99283 is more appropriate. 
 
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 99284 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and moderate 
level of medical decision making." 
 
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 enrollee presented for left hip 
pain. A x-ray of the left hip was negative for fracture. The diagnosis was acute on chronic hip pain. The history 
and exam were appropriate. However, the documentation does not support a moderate level of medical decision 
making. The documentation fails to show more than one problem. The problem was simple, and the review of 
data was minimal. The risk of morbidity was low and minimal. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency room services (procedure code 99284) rendered on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit described by code G0463 
billed for date of service March 17, 2023.  
 
You asked the Plan to pay for G0463. You say that G0463 should be paid as billed because this code does not 
represent preoperative services. The Plan denied your request. The Plan says G0463 is denied because payment 
for this service is included in payment for the enrollee's inpatient stay starting on March 19, 2023. 
 The Plan must follow Medicare rules. Medicare rules say that outpatient non-diagnostic services provided by 
the hospital on the first, second, and third calender days preceding the date of the enrollee's inpatient admission 
must be billed with the inpatient stay unless the hospital attests to the specific non-diagnostic service being 
clinically distinct or independent from the inpatient services by adding condition code 51 on the separately 
billed outpatient claim.  
 
We looked at the file and Medicare rules. We confirmed that G0463 performed on March 17, 2023, was billed 
by the same hospital where the enrollee was admitted from March 19, 2023, to March 25, 2023. This means 
that G0463 was performed within the first, second, and third days preceding the date of the enrollee's 
admission. We confirmed condition code 51 was not billed on the claim for G0463 to indicate it was an 
unrelated outpatient non-diagnostic service. Therefore, per Medicare rules, it should be billed and included 
with the inpatient claim. Based on this information, we decided that Medicare rules for coverage of G0463 
have not been met. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic 
visit described by code G0463 billed for date of service March 17, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 occupational therapy visits. 
 You asked the Plan to pre-approve home health services. You say that you would like reconsideration based on 
the records submitted. 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 that the 
enrollee has refractory chronic functional loss. The record does not provide a rationale for continued therapy 
based on the response to prior 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 5 occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 rendered on February 9, 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 code is not appropriate for 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 code 99236 is "Hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, 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, 85 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 services at issue in this case were not supported by the medical records. Our reviewer found that the medical documentation is 
limited. The level of the visit does not meet the requirements for CPT 99236. There is a more appropriate level 
of care that could be billed. 
 
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 99236 rendered on February 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88377 billed for date of service July 28, 
2023.  
 
You asked the Plan to pay for procedure code 88377. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88377 is 5. The MAI value for this code is 3. You billed 6 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88377 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88377 billed for date of service July 28, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says there is no record from your prescriber that shows you have tried one of the 
preferred drugs (Monovisc, Orthovisc, Synvisc or Synvisc One), or that you have medical reasons that prevent 
you from using one of them.  
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found that step therapy, as outlined by the 
Plan, requires that one of the preferred viscosupplemental treatments (Monovisc, Orthovisc, Synvisc or 
Synvisc-One) be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered or that the Plan's additional required drugs would likely be less effective 
and/or likely have adverse effects for the enrollee. Without the support of the documentation, Euflexxa is not 
approved as step criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service January 23, 
2023.  
 
You asked the Plan to pay for procedure code 88341. You say that the code was billed correctly. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 32 units of this 
code, exceeding the MUE. The documentation does not show that the excess units were provided, correctly 
coded, and medically necessary. The records do not sufficiently document repeat testing that would warrant the 
appended modifier 91. The records do not document any rationale to support the testing of additional units. 
Based on this information, we decided that Medicare rules for coverage of procedure code 88341 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 88341 billed for date of 
service January 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of November 9, 
2023. 
 
You asked the Plan to pre-approve inpatient psych care. You say that the enrollee continues to have behaviors. 
The Plan denied your request. The Plan says the needed services can be provided safely in another setting such 
as residential, partial hospitalization, or outpatient care. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psych care. Our reviewer says 
that the enrollee does not meet criteria for continued inpatient psychiatric care. Our physician reviewer found it 
is not expected that this enrollee would improve in a reasonable period of time beyond the date in question as 
the enrollee was not showing any dangerousness to self or others, auditory or visual hallucinations, or acute 
threat to safety. It does not appear medically reasonable and necessary to have psychiatric care provided at the 
acute inpatient level of care rather than a lower 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 inpatient psych care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued inpatient psychiatric care as of November 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service February 9, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the services are 
not payable. 
 
The Plan must follow Medicare rules. The rules say that VA facilities and military hospitals are excluded from 
participating in Medicare. The rules also say that Medicare payment cannot be made to a provider that is not 
enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of service 
February 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-24 billed for date of service May 9, 
2023. 
 
You asked the Plan to pay for the billed service. You say that medical documentation was provided. The Plan 
denied your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 99213-24 is not supported in the medical record. The file shows that code 99213 was 
provided 1 day prior to major surgical procedure 28308. The medical records show that the enrollee presented 
to the office for a pre-operative visit. The code at issue, billed with modifier 24 is not payable in this case. 
Based on this information, we decided that Medicare rules for coverage of the billed service have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99213-24 billed for date of service 
May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel 
provided on July 24, 2023. 
 
You asked the Plan to pay for the fungal infection PCR panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the guidelines state that fungal infection of the nail 
(tinea unguium or onychomycosis) can be verified by direct microscopic examination with potassium 
hydroxide, fungal culture of desquamated subungual material, or fungal stain of a nail clippings fixed in 
formalin. 
 
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 fungal infection PCR panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the current standard of care for investigation of onychomycosis in a 
toenail is to perform a KOH and or fungal culture to the specimen. These lab tests are inexpensive, sensitive, 
and specific. It is unclear as to why this enrollee's right hallux nail specimen required PCR testing when other 
less expensive and efficacious lab tests (KOH and fungal culture) are available. Therefore, the requested PCR 
testing of this enrollee's right hallux toenail was 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 the fungal infection PCR panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel provided on July 
24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99203-
25) rendered on March 7, 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 criteria for modifier 25 has not been met. 
 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 99203 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 30-44 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 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 records do not 
support that a separate evaluation and management code should be billed. The exam was extremely limited to 
just the knee that the enrollee endorsed pain. The treatment plan was that for an injection. With any procedure, 
the evaluation of the area is built into the procedure code and not separately billable. 
 
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 evaluation and management services (procedure code 99203-25) rendered on March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses billed for date of service January 10, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is relevant 
medical records which support medical necessity.  
 
The file shows that a knee orthosis and suspension sleeve was billed. The record does not contain relevant 
medical records which support medical necessity for the supplies provided in this case. The records provided 
do not document recent injury, a surgical procedure, or instability identified through an objective physical 
exam. Addition codes are not covered if the base code is not covered. Based on this information, we decided 
that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to 
pay for the orthoses billed for date of service January 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 36-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you have major health issues 
and require transportation to medical appointments. The Plan denied your request. The Plan says you have 
exhausted your transportation benefit. 
 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 a maximum of 36 trips per year.  
 
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 trips for routine transportation beyond the Plan's 
36-trip limit.