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

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) during non-intracranial 
surgery (95955), continuous intraoperative neurophysiology monitoring (IONM) (G0453) provided on June 30, 
2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. You 
say that they are supported by the Plan's guidelines. You say that You also say there is not a network 
interpreting physician credentialed at this facility and the hospital cannot provide these specialized services. 
The Plan denied your request. The Plan says the services are considered experimental and investigational. 
 
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 physician services. Our reviewer says 
that EEG and IONM are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the services are considered experimental and investigational for spinal surgery. The reviewer 
found that additional research is needed. Therefore, the reviewer found that the services are 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 physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for the electroencephalogram (EEG) during non-intracranial surgery (95955), continuous 
intraoperative neurophysiology monitoring (IONM) (G0453) provided on June 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99233) rendered on 
March 2, 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) 99233 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 99233 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 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 problem(s) requiring 
admission are of high severity. Typically, 70 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 the provided documentation was 
written by a nurse practitioner, and then addended by the doctor. Neither provided a detailed interval history, 
but rather noted cursory observations. The complexity of the medical decision making is debatable, as the 
doctor notes multiple decisions, but in the setting of the patient being downgraded to the floor.  As such, the 
documentation does not support the billing of CPT 99233. 
 
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 99233) rendered on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (procedure code 99233) rendered 
from April 26, 2022, to April 30, 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 99233 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 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; 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 patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 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 the provided documentation does 
not support a detailed history or medical decision making of high complexity, making CPT code 99233 
insufficiently supported by the documentation. 
 
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 subsequent hospital care (procedure code 99233) rendered from April 26, 2022, to April 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (procedure codes 99223 and 99232) rendered 
from September 18, 2022, to September 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 documentation does not support this level of care. 
 
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 99223: 
 
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 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
CPT 99232: 
 
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 
 
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 provided records do not 
support a comprehensive examination or an expanded problem focused interval history. Therefore, the records 
do not support the use of CPT 99223 on September 18, 2022. Additionally, the records do not include an 
expanded problem focused examination or medical decision making of moderate complexity to justify the CPT 
code 99232 on 9/19/2022.  
 
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 hospital care (procedure codes 99223 and 99232) rendered from September 18, 2022, to 
September 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration stating 
this home ventilator should be approved due to the enrollee's continued decline in respiratory status which has 
resulted in at least three hospital admissions in the last four months. The Plan denied your request. The Plan 
says the records do not show that this requested device is not being used exclusively in CPAP or bi-level PAP 
mode. The request 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has very severe COPD, 
on home oxygen, FEV1 18% of predicted in 2020. The enrollee has been hospitalized 3 times in the last few 
months for acute on chronic respiratory failure. ABGs have been consistent with acute on chronic hypercarbic 
respiratory failure. The enrollee improved in the hospital on BiPAP. This enrollee may benefit from BiPAP 
with 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel 
provided on March 28, 2022. 
 
You asked the Plan to pay for fungal PCR panel testing. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this testing is not indicated as an appropriate means to 
verify fungal infection. 
 
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 fungal PCR panel testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the long-standing standard of care for the evaluation of fungus in toenails is the 
performance of both potassium hydroxide (KOH) and fungal culture on a toenail specimen. These lab tests are inexpensive, sensitive, and specific. It is unclear as to why the enrollee's toenail required PCR testing as 
opposed to KOH and fungal culture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of fungal PCR panel testing have not been met. Therefore, we decided that the 
Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel provided on March 28, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96411, 96417, and 96375 provided on 
October 21, 2022. 
 
You asked the Plan to pay for procedure codes 96411, 96417, and 96375. You say that this service was 
medically necessary. The Plan denied your request. The Plan says these codes are 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 CPT code. In this case, we have confirmed that codes 
96411, 96417, and 96375 are add-on codes and have not been billed with an appropriate primary procedure code. 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 codes 96411, 96417, and 96375 provided on October 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service code A0427 provided on May 31, 2022. 
 
You asked the Plan to pay for ambulance service A0427. You say that you are appealing this denial. The Plan 
denied your request. The Plan says a different code should be billed for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that if an ambulance is called/dispatched but the 
beneficiary dies on the scene prior to the arrival of the ambulance, code A0428 or A0429 as applicable should 
be used.  
 
We looked at the file and Medicare rules. Code A0427 is not appropriate for this claim based on Medicare 
claims processing guidelines. Based on this information, we decided that Medicare rules for coverage of 
ambulance service A0427 have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance service code A0427 provided on May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and a 
segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the enrollee 
has seen multiple doctors do address the swelling and has a history of open wounds as well as truncal edema. 
He presents with edema, decreased range of motion, functional impairment and difficulty completing his 
activities of daily living. He recently sought treatment from wound care for the past month to assist with wound 
healing and compression wraps. Despite these conservative measures, the enrollee is still having swelling in his 
abdominal cavity and his extremities. The Plan denied your request. The Plan says the request is not medically 
necessary because records show the enrollee does not have at least four weeks of regular, daily, multiple-hour 
home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who 
is skilled in and who regularly and successfully uses the appliance provided. The enrollee does not meet criteria 
for approval. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and a segmental pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
sensors and supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a Freestyle Libre 2 CGM and supplies. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the 
CGM and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 2 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre 2 continuous glucose monitor (CGM) sensors and supplies (K0553, K0554).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services (A0425, A0428) provided on June 6, 2022. 
 
You asked the Plan to pay for ambulance services. You say that this transportation was provided when the 
enrollee was discharged from one facility and was transferred to another; therefore, these services are 
separately payable. The Plan denied your request. The Plan says that these services are considered inpatient 
transportation and are included in the payment to the facility. 
 
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 has provided no evidence to support that the enrollee 
maintained inpatient status at one facility during the transport in question. Without evidence that the enrollee 
either maintained inpatient status or was transferred to another building/facility with the same provider, the 
Plans denial is not supported. The Plan has provided no other reason for denial in this case. Therefore, we 
decided that the Plan has to pay for ambulance services (A0425, A0428) provided on June 6, 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 the observation evaluation and management (EM) services 
provided on May 7, 2022, billed with code 99220. 
 
You asked the Plan to pay for the EM services as billed. You say that review of the records confirmed that this 
was billed correctly. The Plan denied your request. The Plan says the records do not support the use of 99220 
to describe this EM service. 
 
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 Initial observation 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 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 problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 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 EM services as billed. Our reviewer says that the EM 
services provided do not support the use of code 99220. Our reviewer found the enrollee presented to the 
emergency department with dizziness and increased blood pressure. While there was a comprehensive history 
and physical exam, the records do not support that the medical decision making was of high complexity. As 
such, code 99220 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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the observation evaluation and management (EM) services provided on May 7, 
2022, billed with code 99220.