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

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on March 23, 2023. 
 
You asked the Plan to pay for drug testing. You say that this test was necessary and is supported as billed. The 
Plan denied your request. The Plan says that this code is not supported in the records 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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records support that drugs 
from 19 different drug classes were tested in this case. Based on this information, we decided that Medicare 
rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for definitive 
drug testing (G0482) provided on March 23, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Perphenazine tablets. 
 
You asked the Plan to pre-approve Perphenazine. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Perphenazine tablets.   
Benefits for Perphenazine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 62324 and 36556 billed for date of service 
March 2, 2023. 
 You asked the Plan to pay for procedure codes 62324 and 36556. You say that these services were necessary 
and are supported in the medical record. The Plan denied your request. The Plan says payment for code 62324 
is bundled into payment for code 00792. The Plan also says that code 36556 is not supported by 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, we have confirmed that code 62324 
is a column II code to column I code 00792. 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.  
 
In relation to code 36556, the CPT Code Manual definition is insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older.  
 
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 36556. Our reviewer says that code 36556 is not 
supported by the medical record. Our reviewer found per CPT guidelines "To qualify as a central venous access 
catheter or device, the tip of the catheter/device must terminate in the subclavian, brachiocephalic (innominate) 
or iliac veins, the superior or inferior vena cava, or the right atrium".  In this case, procedure report does not 
include sufficient documentation to confirm CPT code criteria have been met.  
 
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 36556 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 62324 and 36556 billed for date of service March 2, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 18, 2018, 
to November 23, 2018, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that he 
principal diagnosis was correctly coded and the DRG should be paid as billed. The Plan denied your request. 
The Plan says the principal diagnosis billed of A41.9 (sepsis, unspecified organism) is not supported by the 
medical record. As a result, a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis of for A41.9 (sepsis, unspecified 
organism). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare 
rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services at the 
DRG originally billed. Our reviewer says that the billed principal diagnosis of A41.9 (sepsis, unspecified 
organism) is not supported by the medical record. Our physician reviewer found the patient had leukocytosis of 
11k with bactiuria. The patient was afebrile with normal respiratory rate and blood pressure. They presented 
with syncope and were treated for a presumptive urinary tract infection. The documentation does not support 
sepsis, so code A41.9 is not justified.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 18, 2018, to November 23, 2018, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87500, 87641, 87653, 87798 
and 87801(x3) billed with the XU modifier for date of service January 30, 2023. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87500, 87641, 87653, 87798 and 87801(x3). You 
say that these services were necessary and are supported in the medical record. The Plan denied your request. 
The Plan says hese codes are not supported in the record as they were reported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -XU modifier if 
the service billed with the modifier indicates an Unusual Non-Overlapping 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 procedure codes 87150, 87481, 87500, 87641, 87653, 87798 and 87801(x3). Our reviewer says that the use of the XU modifier for procedure codes 
87150, 87481, 87500, 87641, 87653, 87798 and 87801(x3) is not supported by the medical record. Our 
physician reviewer found although you reported the XU modifier for these codes, the laboratory report does not 
include documentation to support an unusual non-overlapping service from code 87801. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87500, 87641, 87653, 87798 and 87801(x3) 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 
87500, 87641, 87653, 87798 and 87801(x3) billed with the XU modifier for date of service January 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87481, 87653, and 87798 billed with the XU modifier 
for date of service January 12, 2023. 
 
You asked the Plan to pay for codes 87481, 87653, and 87798 billed with the XU modifier. You say that these 
services are supported in the records. The Plan denied your request. The Plan says these codes are included in 
87801. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -XU modifier if 
the service billed with the modifier indicates an Unusual Non-Overlapping 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 codes 87481, 87653, and 87798 billed with the XU modifier. Our reviewer says that the use of the XU modifier to allow for separate payment of codes 
87481, 87653, and 87798 is not supported by the medical record. Our physician reviewer found although you 
reported the XU modifier for these codes, the laboratory report does not include documentation to support an 
unusual non-overlapping service from 87801. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 87481, 87653, and 87798 billed with the XU modifier have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 87481, 87653, and 87798 billed with the 
XU modifier for date of service January 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 23430-59 billed for date of service November 23, 2022. 
 
You asked the Plan to pay for code 23430-59. You say that ode 23430-59 was a separate and distinct procedure 
from the reverse total shoulder arthroplasty. The Plan denied your request. The Plan says code 23430-59 is 
considered inclusive to code 23472-LT. The use of the 59 modifier to allow for separate payment is not 
supported because the records do not show that the procedure was distinct or separate from other services 
performed. 
 
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 code 23430-59. Our reviewer says that code 
23430-59 is not supported by the medical record. Our physician reviewer found the procedure report 
documents a shoulder arthroscopy and bicep tenodesis, however a modifier 59 distinct procedural service is not supported.  The documentation describes both procedures performed and does not support a separate incision 
or anatomical area, and therefore this code would not be reported separately. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 23430-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 23430-59 billed for date of service November 23, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0481) provided on March 27, 2023. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says that the physician order provided does not 
include details regarding which drugs are requested to be tested in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the requested drugs for testing are included in the records provided. 
The provider submitted a multipage document, signed by the same provider prior to the services at issue, 
detailing what drugs are requested for testing under a "custom panel" with a profile number of "2". This is the 
panel requested on the physician order form submitted and signed by the same physician. The records provided 
do indicate which drugs were requested for testing, and this list matches those which were tested. The Plan's 
denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for drug testing (G0481) 
provided 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on March 23, 2023. You asked the Plan to pay for definitive drug testing. You say that this testing was necessary and ordered by 
the enrollee's treating physician. The Plan denied your request. The Plan says there are no screening test results 
to support the necessity of the definitive testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The rules say that definitive drug testing is indicated in certain conditions. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of definitive drug testing have been met. 
Specifically, there is no evidence that any presumptive drug testing was performed prior to the services at issue. 
Without presumptive testing, then we cannot verify that the definitive testing provided was indicated according 
to Medicare rules. Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0483) 
provided on March 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services billed for dates of 
service March 8, 2023, to April 17, 2023. 
 
You asked the Plan to pay for the SNF services. You say that you would like to appeal for payment of this 
claim because these are covered services. The Plan denied your request. The Plan says these services are not 
payable based on the Type of Bill code that was on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that SNF providers must bill the appropriate Type of 
Bill code on their claims.  The fourth digit of the Type of Bill code is called a 'frequency' code.  When the 
fourth digit of the Type of Bill code is a 0, the provider is indicating that this is a nonpayment/zero payment 
claim.  This is used when the provider does not anticipate payment for the bill, but it is informing the payer 
about a period of non-payable confinement. 
 
In this case, the provider billed the claim for these SNF services with Type of Bill code 0210.  The 0 in the last 
digit indicates that this is not a payable claim. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for 
skilled nursing facility (SNF) services billed for dates of service March 8, 2023, to April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99222 billed for date of service January 31, 2023. 
 
You asked the Plan to pay for code 99222. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 99222 is not supported by 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 99222 is initial hospital inpatient care, typically 50 
minutes. The code requires a comprehensive history, a comprehensive examination, and medical decision 
making of moderate complexity. 
 
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 99222. Our reviewer says that code 99222 is not 
supported buy the medical record. Our reviewer found the provided records in this case do not document a comprehensive history with all of the following: a chief complaint, an extended history of present illness, a 
review of all additional body systems and a complete past, family and social history. As the comprehensive 
history is not documented, code 99222 is not supported.  
 
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 99222 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99222 billed for date of service January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 Liquid CDx testing (0326U) billed for date of 
service September 21, 2022. 
 
You asked the Plan to pay for Guardant360 testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says the date of service reported on 
this claim is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. There are few exceptions to this rule. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 testing have not been met. Specifically, the records provided show that the specimen 
in question is a blood sample. This means that there is no eligible exception to the date of service rule in this 
case. This means that the appropriate date of service to report for the documented services would be the date of 
specimen collection, which is noted as September 12, 2022. Therefore, we decided that the Plan does not have 
to pay for Guardant360 Liquid CDx testing (0326U) billed for date of service September 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says confirmation 
obtained, this drug will be dispensed by a pharmacy and not from the physician as a buy and bill. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Gelsyn-3 (J7328).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80299, 80324, 80332, 80335, 80346, 80348, 
80353, 80354, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80364, 80365, 80367, 80369 and 80372 
billed for date of service December 12, 2022. 
 
You asked the Plan to pay for procedure codes 80299, 80324, 80332, 80335, 80346, 80348, 80353, 80354, 
80356, 80357, 80358, 80359, 80360, 80361, 80362, 80364, 80365, 80367, 80369 and 80372. You say that these services were necessary and are supported in the medical records. The Plan denied your request. The Plan 
says the billed codes are invalid for Medicare purposes. Code 80299 is recognized; however, the panel 
provided would be better reported with a single code. 
 
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 codes 80324, 80332, 80335, 80346, 80348, 80353, 80354, 80356, 80357, 80358, 
80359, 80360, 80361, 80362, 80364, 80365, 80367, 80369 and 80372 has a Status Indicator of I on the 
Physician Fee Schedule. This means that procedure codes 80324, 80332, 80335, 80346, 80348, 80353, 80354, 
80356, 80357, 80358, 80359, 80360, 80361, 80362, 80364, 80365, 80367, 80369 and 80372 is not valid for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure codes 
80299, 80324, 80332, 80335, 80346, 80348, 80353, 80354, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 
80364, 80365, 80367, 80369 and 80372 have not been met.  
 
In addition, although code 80299 is recognized by Medicare, the CPT code manual definition of code 80299 is 
quantitation of therapeutic drug, not elsewhere specified. Without the other codes in this case, this single code 
is not supported. The record shows that the service(s) provided in this case is a definitive drug testing panel. 
There is a more appropriate HCPCS code (G0480-G0483) to report this panel. Therefore, we decided that the 
Plan does not have to pay for procedure codes 80299, 80324, 80332, 80335, 80346, 80348, 80353, 80354, 
80356, 80357, 80358, 80359, 80360, 80361, 80362, 80364, 80365, 80367, 80369 and 80372 billed for date of 
service December 12, 2022.