Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluations (D0120), the cleanings 
(D1110), and an extraction (D7140) for tooth #3 provided by an out-of-network provider on January 24, 2022, 
March 29, 2022, May 31, 2022, July 25, 2022, September 21, 2022, September 27, 2022, and November 17, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that the charges for the dental procedures are 
not reasonable. The Plan denied your request. The Plan says you are responsible for any charged amount above 
the Plans cost-sharing amount when your services are received from an out-of-network provider. Also, your 
benefit for the cleanings has already been exhausted. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. On 
January 24, 2022, the total allowed amount for the cleaning was $41 and the total charged amount was $102 
with an enrollee responsibility of $61 ($102 charged - $41 allowed). On March 29, 2022, the total allowed 
amount for the cleaning was $41 and the total charged amount was $104 with an enrollee responsibility of $63 
($104 charged - $41 allowed. On March 29, 2022, the total allowed amount for the evaluation was $19 and the 
total charged amount was $58 with an enrollee responsibility of $39 ($58 charged - $19 allowed). On 
September 21, 2022, the total allowed amount for the evaluation was $19 and the total charged amount was $58 
with an enrollee responsibility of $39 ($58 charged - $19 allowed). On September 27, 2022, the total allowed 
amount for the extraction was $56 with a coinsurance amount of $28 ($56 allowed x 50% coinsurance). The 
total charged was $262 and the total amount allowed was $56 leaving the difference of $206 ($262 charged - 
$56 allowed). The total enrollee responsibility for the extraction was $234 ($28 coinsurance + $206 difference). 
The record shows your benefit for the cleanings was exhausted on the date of service of March 29, 2022; 
therefore, the denial for the cleanings on May 31, 2022, July 25, 2022, September 21, 2022, and November 17, 
2022, was correct. Therefore, we decided that the Plan does not have to pay more for the periodic oral 
evaluations (D0120), the cleanings (D1110), and an extraction (D7140) for tooth #3 provided by an out-of-
network provider on January 24, 2022, March 29, 2022, May 31, 2022, July 25, 2022, September 21, 2022, 
September 27, 2022, and November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4550 billed for date of service November 14, 2022. 
 
You asked the Plan to pay for code A4550. The Plan denied your request. The Plan says code A4550 is 
considered bundled and not separately payable. 
 
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 code A4550 has a status indicator of B on the Physician Fee Schedule. This means that code 
A4550 is not separately payable. Based on this information, we decided that Medicare rules for coverage of code A4550 have not been met. Therefore, we decided that the Plan does not have to pay for code A4550 billed 
for date of service November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (97597, 11721) provided on August 9, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97597 is "Debridement (eg, high pressure waterjet 
with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, 
devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound 
assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) 
surface area; first 20 sq cm or less". The CPT Code Manual definition of code 11721 is "Debridement of nail(s) 
by any method(s); 6 or more". 
 
We find that CPT codes 97597 are not supported in the medical record. Specifically, the records do not indicate 
the surface area of the debridement to support code 97597. Additionally, the records do not indicate the number 
of nails to support code 11721. 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 (97597, 
11721) provided on August 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cancer screening (81406) provided on September 
20, 2022. 
 You asked the Plan to pay for hereditary cancer screening. You say that this test was medically necessary and 
was ordered by the enrollee's treating physician. The Plan denied your request. The Plan says this test is not 
covered for screening purposes in an enrollee with no personal history of cancer. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, hereditary cancer screening, was requested solely for screening purposes. The 
records note that the enrollee has no personal history of any kind of cancer. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cancer 
screening (81406) provided on September 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care from 
March 18, 2023, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found there is no documentation that daily skilled services are required. Although records 
document the enrollee is very limited functionally, provided records do not document a significant decline in 
the patients functional status compared to the enrollee's recent baseline to necessitate daily inpatient skilled 
therapy services. Based on the medical records provided there is no documentation that the enrollee requires 
the services on an inpatient basis, only in a SNF setting. Records support that services in the long-term care 
facility on a part time basis are appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continuation of skilled nursing facility (SNF) care from March 18, 2023, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is medically necessary. The 
Plan denied your request. The Plan says the ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found there are no pulmonary function tests to confirm COPD and assess severity. If you do have 
severe COPD and chronic carbon dioxide (CO2) retention, may benefit from bilevel positive airway pressure 
(BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an outpatient. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on October 22, 2022, through 
October 23, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the services provided were emergent 
and it was appropriate to take the enrollee to the nearest hospital for immediate care. The Plan denied your 
request. The Plan says that the enrollee's care could have been provided at an observation level of care. 
 
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 records provided to us by the Plan were incomplete. The partial 
medical records used by the Plan in making their determination were submitted by the provider at the time of 
the authorization request.  In order to make a proper determination regarding the retrospective hospital stay, we 
would need complete medical records from the entire inpatient stay. There is no evidence that the Plan made 
reasonable attempts to obtain these complete medical records. Therefore, we decided that the Plan has to pay 
for inpatient hospital services provided on October 22, 2022, through October 23, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99220 provide on September 12, 2022 to 
September 14, 2022. 
 
You asked the Plan to pay for procedure code 99220. You say that this service was medically necessary. 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 99220 is observation care requiring a comprehensive 
history; a 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 procedure code 99220. Our reviewer says that the records 
provided do not support code 99220. Our reviewer found the documented medical decision making is not 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 procedure code 99220 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99220 provide on September 12, 2022 to September 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aquatic therapy 
 
You asked the Plan to pre-approve aquatic therapy. You say that the records provided support the need for 
aquatic therapy. The Plan denied your request. The Plan says the requested services do not meet the medical 
necessity criteria. 
 
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 aquatic therapy. Our reviewer says that 
aquatic therapy is not considered medically reasonable and necessary in this case. Our physician reviewer 
found you have degenerative spondylosis, arthritis of the cervical spine. You have already been doing aquatic 
therapy. A recent note from December 30, 2022, states that you presented with exacerbation of your neck pain 
which was improving. You reported increased strength since starting physical therapy and were doing home 
exercises without issue. Your pain level was two out of ten. However, based on the documentation, you are 
able to perform and benefit from home, land-based exercises and do not require aquatic 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 aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve aquatic therapy
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 19, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was billed 
with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. 
The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the 
inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes 
place.  
 
We looked at the file and Medicare rules. In this case, it is inappropriate to bill POS code 21, as the 
documentation shows that the enrollee was under outpatient status on the date of service in question. 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 provided on September 19, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99232, 95816) provided on August 6, 2021, and August 7, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed codes 
are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99232 is "Subsequent hospital care, per day, for the evaluation and management of a patient, which 
requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded 
problem focused examination; 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 patient is 
responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at 
the bedside and on the patient's hospital floor or unit". The CPT Code Manual definition of code 95816 is 
"Electroencephalogram (EEG); including recording awake and drowsy". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of codes 99232 
and 95816 is not supported by the records provided. Our reviewer found that medical documentation does 
support evaluation and management code 99232, as the medical decision making does show this is the correct 
level. The medical documentation does support the use of procedure code 95816 as the electroencephalogram 
(EEG) was performed and used to determine the enrollee's seizure activity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
the services (99232, 95816) provided on August 6, 2021, and August 7, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee cannot get out of a 
traditional bed. The Plan denied your request. The Plan says while the supplied documentation may support a 
fixed height or even a variable height hospital bed, it does not support the coverage criteria of the local 
coverage determination for a semi-electric hospital bed. 
 
The Plan follows Medicare rules. Medicare rules say that a semi-electric hospital bed is covered if the 
beneficiary meets one of the criteria for a fixed height bed and requires frequent changes in body position 
and/or has an immediate need for a change in body position.  
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 semi-electric hospital bed. Our 
reviewer says that the enrollee does not meet the coverage criteria for a semi-electric hospital bed. Our 
physician reviewer found the enrollee is experiencing progressive weakness that is impacting their ability to 
transfer and ambulate as well as perform daily activities. The enrollee is noted to have anti-gravity strength. 
Our reviewer found that the enrollee may require a hospital bed for positioning that is not feasible with an 
ordinary bed or elevation of the head of the bed greater than 30 degrees. However, the documentation does not 
indicate that the enrollee is unable to re-position themself while in bed, requires frequent re-positioning, or an 
immediate change in position, which is required for a semi-electric hospital bed versus a standard hospital bed. 
Our physician reviewer found that therefore, the requested semi-electric hospital bed (E0260) is not medically 
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 a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service September 1, 
2022. 
 
You asked the Plan to pay for procedure code 88321. You say that this service was medically necessary. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 88321 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88321 billed for date of service September 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the face-down positioning device (E1399) provided on 
September 12, 2022. 
 
You asked the Plan to pre-approve the face-down positioning device. You say that this equipment was 
necessary to help your retina reattach.  The Plan denied your request. The Plan says this equipment is 
considered a precautionary device and is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the face-down positioning device (E1399) provided on 
September 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9326 billed for date of service August 29, 
2022. 
 
You asked the Plan to pay for procedure code S9326. You say that this claim should be reprocessed because it 
was continuation of therapy. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes. 
 
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 code S9326 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9326 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9326 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9326 billed for date of service August 29, 2022.