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

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99222) rendered on 
February 5, 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 99222 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 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate 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 problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit." 
 
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 documentation 
does not support the CPT code 99222. The documentation available for review does not support that the 
encounter required medical decision making of moderate complexity. 
 
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 initial hospital care (procedure code 99222) rendered on February 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories (K0837, 
E2361x2, E1028x2, E1002, E0955, E1012, E2311). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested wheelchair 
and accessories are medically necessary. The Plan denied your request. The Plan says there are significant 
contradictions in the measured ability of the enrollee to ambulate and use alternative devices for mobility when 
in pain or fatigued between the original mobility review and the in-home independent assessment. 
 
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 a power wheelchair and accessories. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the documentation is conflicting. The documentation indicates the 
enrollee has a mobility deficit, but the documentation does not support that the enrollee is unable to effectively 
perform his MRADLS in the home. The documentation does not reveal that the enrollee is unable to use a 
manual wheelchair in the home. The documentation indicates that the enrollee leaves a borrowed group 2 
wheelchair outside the home. The periscope evaluation indicates that the enrollee's ambulatory problems occur 
mainly with community mobility. The documentation does not support that the enrollee requires the requested 
power wheelchair and that this wheelchair will significantly improve MRADL participation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 power wheelchair and accessories (K0837, E2361x2, 
E1028x2, E1002, E0955, E1012, E2311).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212-25) provided on July 28, 2022. 
 
You asked the Plan to pay for the office visit. You say that this service is supported in the medical record for 
separate payment. The Plan denied your request. The Plan says modifier -25 is not supported in this case to 
show that this office visit is separate and distinct from the minor procedure (36478) performed on the same 
date. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the office visit. Our reviewer says that the -25 modifier 
reported with code 99212 is not supported for separate payment in this case. Our reviewer found that this 
evaluation and management service documents that the reason for the appointment is for endovenous laser 
ablation (EVLA), right perforator, and an ultrasound follow up of the left perforator. The evaluation and 
management service provided does not include documentation of a significant, separately identifiable service 
provided that is not related to the procedure performed. Therefore, this service denied correctly. 
 
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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for the office visit (99212-25) provided on July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99236) provided on August 14, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 99236 is "Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: 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) requiring admission are of high severity. Typically, 55 
minutes are spent at the bedside and on the patient's hospital floor or unit".  
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 99236 is 
not supported by the records provided. Our reviewer found that there was no documentation of a 
comprehensive history or medical decision making of high complexity. 
 
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 (99236) provided on August 14, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory testing provided on January 19, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that the ordering physician ordered this wound 
panel because they felt it was medically necessary. The Plan denied your request. The Plan says that the claim 
processes correctly. 
 
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 Plan did not indicate why the services at issue were overpaid. 
Therefore, we decided that the Plan has to pay for the laboratory testing provided on January 19, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0299, G0152, G0300) provided on 
January 17, 2022 to March 17, 2022. 
 
You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules state that for periods of care beginning on or after January 1, 2020, the duration of a period is 30 days. 
 
We find that the home health services are not supported. Specifically, 59 days were billed for a single period of 
care. Based on this information, we decided that Medicare rules for coverage of the home health services have 
not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0299, 
G0152, G0300) provided on January 17, 2022 to March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service October 8, 2022. 
 
You asked the Plan to pay for code 99223. You say that this code was appropriate for the services rendered. 
The Plan denied your request. The Plan says the medical records do not support code 99223. The medical 
records submitted do not support a comprehensive history and medical decision making of high complexity. 
 
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 nitial hospital care evaluation and management 
of a patient that requires 3 key components.  The 3 key components are a comprehensive history, 
comprehensive examination and medical decision making of high 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 99223. Our reviewer says that code 99223 is not supported by the medical record. Our reviewer found the patient is a 73-year-old female with a medical history 
including fibromyalgia, hypertension and diabetes mellitus who presented to the emergency department with 
neck pain. She was admitted to the hospital on October 7, 2022, with a diagnosis of pain. The inpatient plan of 
care was for pain control and diagnostic studies. The documentation available for review does not support the 
encounter required decision making of high complexity. 
 
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 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service October 8, 2022.
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 all 
services that would be provided in the LTACH are being provided already in the current acute care setting 
already approved. 
 
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 enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99236 rendered on July 19, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the service is not supported without the required documentation. 
 
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 "Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: 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) requiring admission are of high severity. Typically, 55 
minutes are spent at the bedside and on the patient's hospital floor or unit."  
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 based on the provided 
documentation, the physical examination was detailed. However, the history was not comprehensive, and the 
medical decision making would not be considered high complexity, but perhaps moderate or low complexity.  
 
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 July 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the epidural steroid injection (ESI) for L5-S1 (62323). 
 
You asked the Plan to pre-approve the injection. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested service is not 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 the injection. Our physician reviewer 
found the documentation does not reveal objective evidence of failure of four (4) weeks of physical therapy for 
the enrollee's lumbar radicular symptoms. The documentation does not reveal that the enrollee has failed 
nonsteroidal anti-inflammatory drug (NSAIDS). The requested epidural steroid injection at L5-S1 is not 
medically necessary per LCD L39242. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the epidural steroid injection (ESI) for L5-S1 (62323).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the CT, heart, without contrast material, with quantitative 
evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the Medicare rules have not been met. 
 
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 service. Our physician reviewer 
found the enrollee has a lifetime risk of coronary vascular disease of 10.4%. The NCD criteria of CT calcium 
scoring includes patients with a lifetime risk of 9-19%. While the enrollee is currently asymptomatic, the 
enrollee does qualify for the test per LCD guidelines. 
 
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 service have been met. Therefore, we decided that the Plan has to pre-
approve the CT, heart, without contrast material, with quantitative evaluation of coronary calcium (75571).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is not considered medically reasonable and necessary to perform multiple blocks 
during the same session as epidural steroid injections (ESIs). 
 
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 the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the provider states in a 1/24/23 visit that they plan to do a left sacroiliac and left shoulder 
injection. It is not medically reasonable and necessary to perform multiple blocks during the same session as 
the epidural steroid injections except for a facet synovial cyst and epidural performed in the same session. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection (ESI).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed with 2EB21 rendered on August 
2, 2021. 
 
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 services are not payable 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. 
 
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 documentation 
doesnt support the correct Patient Driven Payment Model (PDPM) was submitted by the organization. The 
documentation available for review does not support the initial assigned functional impairment level by rehab 
services. The partial adjustment to PDPM 2EA21 was appropriate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for home health services billed with 2EB21 rendered on August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Covid-19 test (U0004) and infectious agent detection by 
nucleic acid (U0005) provided on May 31, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that you disagree with the denial and request 
reconsideration of payment. The Plan denied your request. The Plan says the claim was processed and paid at 
the correct Medicare rate. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory testing have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed amount as 
payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare 
allowed payment. Therefore, we decided that the Plan does not have to pay for a Covid-19 test (U0004) and 
infectious agent detection by nucleic acid (U0005) provided on May 31, 2022.