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

 
We decided that the Plan does not have to pay for code 99213 billed for dates of service December 19, 2022, 
and December 20, 2022. 
 
You asked the Plan to pay for code 99213. You say that because the hospitalization was authorized, any 
services that the patient received during the hospitalization should fall under that authorization. The Plan 
denied your request. The Plan says this code was not billed correctly. 
 
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 99213 is Established patient office or other outpatient 
visit, 20-29 minutes. 
 
 We find that CPT code 99213 is not supported in the medical record. Specifically, code 99213 is to be used to 
bill for office visits.  The services in dispute did not occur in an office.  Rather, the records confirm that these 
were consultations that occurred with a patient during an inpatient hospitalization.  A different code is used for 
inpatient hospital consultations.  Office visit codes should not be used in this scenario. Based on this 
information, we decided that Medicare rules for coverage of code 99213 have not been met. Therefore, we 
decided that the Plan does not have to pay for code 99213 billed for dates of service December 19, 2022, and 
December 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 0241U for date of service 
February 23, 2023. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have 
not been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 0241U 
for date of service February 23, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 12054 and 99285 rendered on December 25, 
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 Current Procedural Terminology (CPT) code 12054 and 99285 remain 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 the denied codes is: 
 
CPT 12054: 
 
Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm  
CPT 99285: 
 
Emergency department visit for the evaluation and management of a patient, which requires these 3 key 
components within the constraints imposed by the urgency of the patient's clinical condition and/or mental 
status: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function 
 
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 documented physical 
examination is not comprehensive. The documented medical decision making is not of high-complexity.  As 
such, the billing of CPT 99285 is not supported. The laceration repair, while large, was not intermediate (ex, 
layered closure, heavily contaminated requiring debridement).  As such, the billing of CPT 12054 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 12054 and 99285 rendered on December 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies billed with codes A4216, A4450, and 
A6196 for date of service October 27, 2022. 
 
You asked the Plan to pay for the medical supplies. You say that you have provided the electronically signed 
prescription for these items. 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 a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain a valid physician order. Specifically, the 'electronic prescription' you provided 
does not include any codes for the items requested, and only lists one item (not three separate ones) as even 
being requested by the physician. Further, none of the units billed for any of these three codes matches the 
number of units that the physician listed in this 'electronic prescription'.  Therefore, we decided that the Plan 
does not have to pay for medical supplies billed with codes A4216, A4450, and A6196 for date of service 
October 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve an MRI. You say that this should be covered. The Plan denied your request. 
The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI. Our reviewer says that the 
requested MRI is not shown in the records to be medically necessary. Our physician reviewer found the 
submitted records do not include a physical exam or x-rays to show why this is indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 2, 2022, billed 
with codes 81210, 81275, 81235, 81404, 81405 and 81479. 
 
You asked the Plan to pay for genetic testing. You say that this was medically necessary. 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 was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 2, 2022, billed with codes 81210, 81275, 81235, 81404, 81405 and 81479.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on August 11, 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 Current Procedural Terminology (CPT) code 99285 remains 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 showed a 
detailed history and physical but did not support a presenting highly severe problem posing immediate threat to 
life and function. The enrollee appears to have had an uncomplicated urinary tract infection. 
 
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 department services (procedure code 99285) rendered on August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services billed with codes 98941 and 98943 for 
dates of service September 19, 2022, to November 12, 2022. 
 
You asked the Plan to pay for the chiropractic services. You say that these services were covered the previous 
year. The Plan denied your request. The Plan says code 98941 was not billed with the appropriate modifier.  
The Plan says that code 98943 is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The rules also say that chiropractic providers are 
required to bill their services using the AT Modifier to indicate active treatment. 
 
In this case, there are two issues present.  In relation to billed code 98943, this code represents chiropractic 
manual manipulation of an area other than the spine.  Medicare only covers manual manipulation of the spine, 
so this code cannot be covered. 
 In relation to code 98941, this code does represent a covered chiropractic service.  However, your provider did 
not bill this service correctly.  Specifically, the provider failed to append the AT modifier to their claim, which 
is required for Medicare payment.  Because this claim was not billed correctly, the Plan cannot be required to 
pay it.  You may contact the provider directly to ask them to submit a corrected claim for this service. 
 
Therefore, we decided that the Plan does not have to pay for chiropractic services billed with codes 98941 and 
98943 for dates of service September 19, 2022, to November 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genicular nerve radiofrequency ablation rendered on 
December 21, 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 this service is excluded from coverage. 
 
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that genicular nerve blocks and genicular nerve ablation are considered investigational and not medically 
necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery.  The review has determined that the requested genicular nerve radiofrequency ablation of 
the left knee for chronic knee pain 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for genicular nerve radiofrequency ablation rendered on December 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care provided on December 31, 2022. 
 
You asked the Plan to pay for hospital care. You say that this was billed with the correct diagnosis codes. The 
Plan denied your request. The Plan says the billed diagnosis codes should not be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that a type 1 Excludes note on a diagnosis code is a 
pure excludes note. It is used when two conditions cannot occur together, such as a congenital form versus an 
acquired form of the same condition. 
 
We looked at the file and Medicare rules. The service at issue was billed with diagnosis codes R73.9, 
hyperglycemia, unspecified, and E11.00, type 2 diabetes mellitus with hyperosmolarity without nonketotic 
hyperglycemic-hyperosmolar coma (NKHHC). Code R73.9 has a type 1 Excludes note for diagnosis codes E08 
to E13. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care provided on December 31, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88341, 88342, 88360) provided on 
August 25, 2022. 
 
You asked the Plan to pay for pathology services. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with a required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee 
schedule for the technical component (TC) of services furnished in institutional settings where the TC service 
is bundled into the facility payment, e.g., hospital inpatient and outpatient settings. 
 
We looked at the file and Medicare rules. The services at issue have both a professional and technical 
component and were provided in a hospital outpatient setting, but were not billed with a modifier to indicate 
only the professional component is being billed. Based on this information, we decided that Medicare rules for coverage of pathology services have not been met. Therefore, we decided that the Plan does not have to pay for 
pathology services (88341, 88342, 88360) provided on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement, muscle and/or fascia (includes epidermis, 
dermis, and subcutaneous tissue, if performed); first 20 sq cm or less rendered on July 13, 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 Current Procedural Terminology (CPT) code 11043 remains 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 11043 is "Debridement, muscle and/or fascia (includes 
epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less." 
 
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 provided 
does not include sufficient documentation to validate that CPT 11043 was rendered in this case. The procedure 
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 debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if 
performed); first 20 sq cm or less rendered on July 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on January 11, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on January 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87481, 87653, and 87798 billed for date of 
service August 23, 2022. 
 
You asked the Plan to pay for procedure code 87481, 87653, and 87798. You say that this should be paid for. 
The Plan denied your request. The Plan says the denied codes remain not supported. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87481, 87653, and 87798 are a column II code to column I codes 87801 and 87150. 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 87481, 87653, 
and 87798 billed for date of service August 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88344 billed for date of service January 30, 
2023.   
You asked the Plan to pay for procedure code 88344. You say that you disagree with the 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 88344 is 6. The MAI value for this code is 3. You billed 9 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 88344 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88344 billed for date of service January 30, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says your care needs could be met with home health care, or outpatient therapy 
services once your 100-days are up. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from February 27, 2023, 
through June 26, 2023. The Plan has covered 100 days of SNF care. 
 
 
 
 Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to regain their maximum function. The Plan denied your request. The Plan says the enrollee does not meet 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.