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

 
We decided that the Plan does not have to pay for the observation care (99226), provided on December 2, 
2020. 
 
You asked the Plan to pay for the observation care. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the member was incarcerated on the date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that a state or local government that has custody of a 
Medicare beneficiary under a penal statute has a financial obligation to pay for the cost of healthcare items and 
services unless the State can demonstrate certain requirements are met and the claim is billed with a modifier or condition code to indicate the requirements are met.  
 
We looked at the file and Medicare rules. The record indicates that the enrollee was incarcerated at the time of 
service, but there is no documentation that the State would require the enrollee to pay for healthcare services. 
Based on this information, we decided that Medicare rules for coverage of the observation care have not been 
met. Therefore, we decided that the Plan does not have to pay for the observation care (99226), provided on 
December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair with tilt and recline, and 
accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the enrollee needs a 
power wheelchair with power tilt due to their limited mobility and inability to easily reposition themself. You 
say that a power wheelchair with tilt is medically necessary to improve the enrollee's mobility and reduce risk 
of further developing pressure sores. You say that this will allow the enrollee to perform daily activities such as 
going to the restroom, going to the kitchen, cleaning, and no longer being bed bound. The Plan denied your 
request. The Plan says there is no indication that the enrollee is capable of operating the requested power 
wheelchair independently. 
 
The Plan follows Medicare rules. Medicare rules say that if the base power wheelchair is not covered, all 
related accessories will also be denied.  
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 group 2 power wheelchair is not medically necessary. Our physician 
reviewer found the documentation indicates the enrollee cannot overcome their mobility deficit with a cane, 
walker, or manual wheelchair. The reviewer found that the enrollee has frontal lobe atrophy, a history of 
hallucinations, memory loss with suspected dementia, and legal blindness which is not consistent with the 
statement that the enrollee can safely operate the requested power wheelchair. The reviewer found that the 
documentation does not clearly reveal that the enrollee's caregivers cannot propel a manual wheelchair. 
Therefore, the reviewer found that the requested power wheelchair 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 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 with tilt and recline, and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services rendered on 
June 8, 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 99239-FS (1 Unit) 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 99239 is "Hospital discharge day management; more than 
30 minutes." 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the records only support that 
26 minutes of services were rendered in this case. 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 discharge day management services rendered on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20610, 77002 and J7329 billed for date of 
service August 9, 2022. 
 
You asked the Plan to pay for procedure codes 20610, 77002 and J7329. You say that the services at issue have 
been billed correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 find that CPT code 20610 is not supported in the medical record. Specifically, CPT code 20610 has been 
reported with modifier LT in this case to indicate a left-sided administration service. The diagnosis code 
reported with the CPT code indicates a right-sided condition. Based on this information, we decided that 
Medicare rules for coverage of CPT code 20610 have not been met. Additionally, we have confirmed that code 
77002 is an add-on code and has not been billed with an appropriate primary procedure code. Code J7329 has 
not been billed with a valid administration 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 20610, 77002 and 
J7329 billed for date of service August 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx Squamous Cell Carcinoma test (0315U) 
provided July 19, 2022. 
 You asked the Plan to pay for the DecisionDx SCC test. You say that you are requesting this be reprocessed 
and paid. The DecisionDx-SCC test is a covered Medicare benefit. The Plan denied your request. The Plan says 
that It is not medically necessary since the definitive diagnosis is not uncertain, and there is no documentation 
that the test will directly impact the treatment of the enrollee. 
 
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 DecisionDx SCC testing. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has diagnosis of invasive well-differentiated 
squamous cell carcinoma, involving all biopsy borders. There is no establishment of molecular diagnosis of 
inheritable disease or germ-line mutations. There is no mention of venous thrombi or thromboembolism. There 
is no medical record or notes to support that this testing will help guide the enrollees treatment or directly 
impact enrollees treatment. The review has determined that the enrollee does not meet guideline criteria. 
NCCN for squamous cell skin cancer does not support DecisionDx SCC testing in its guidelines as part of 
treatment or as a guide to treatment with SCC. 
 
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 DecisionDx SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the DecisionDx Squamous Cell Carcinoma test (0315U) provided July 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that you are appealing this denial. The Plan denied your 
request. The Plan says Opdivo is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our reviewer says that the 
enrollee does not meet criteria for Opdivo. Our physician reviewer found the requested use of Opdivo is not 
Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The requested use is not supported 
by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Opdivo.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted multianalyte assay with algorithmic analysis 
(81599) provided on June 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the Nodify CDT test. You say that based on the information provided in this 
appeal, you request reconsideration of payment for the Nodify CDT test (CPT 81599) and reimburse 
accordingly. The Plan denied your request. The Plan says enrollees must receive their medical services from 
an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the unlisted multianalyte assay with algorithmic 
analysis (81599) provided on June 16, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the NeuroIDgenetix multi-gene panel test (81479) provided 
June 9, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the test was ordered for the enrollee after the 
ordering physician made a professional determination of medical necessity. The Plan denied your request. The 
Plan says this test is experimental and investigational, as there is insufficient peer-reviewed evidence of an 
outcomes benefit associated with this test. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the NeuroIDgenetix multi-gene panel test (81479) provided June 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that services are medically necessary. The Plan denied 
your request. The Plan says you do not meet the Medicare criteria for admission to an IRF. The services you 
need can be provided safely in an alternate level of care such as discharge to a skilled nursing facility (SNF). 
 
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 there are no complex nursing or rehabilitation needs. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
  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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 26, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 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 procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that continued SNF services are necessary to help you 
gain your independence. The Plan denied your request. The Plan says the SNF services you are getting no 
longer meet the rules to continue. 
 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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99220 and 99226 provided on November 10, 2021, 
and November 11, 2021. 
 
You asked the Plan to pay for codes 99220 and 99226. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 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. The CPT Code Manual definition of code 99226 is subsequent observation 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 codes 99220 and 99226. Our reviewer says that the 
documentation does not support the codes billed. Our reviewer found the records do not note the enrollee's 
admission status. The records note that a follow-up was scheduled for November 12, 2021, while 
simultaneously noting that the inpatient encounter was November 12, 2021, to November 13, 2021. The history 
and physical exam states that the length of stay was anticipated to be less than two midnights, but no provider 
orders are submitted for review. As such, the records are insufficient to conclusively show when and on what 
status the enrollee was hospitalized. Therefore, codes 99220 and 99226 are 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 codes 99220 and 99226 have been met. Therefore, we decided that the Plan 
does not have to pay for codes 99220 and 99226 provided on November 10, 2021, and November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the electrodes (A4595) provided on September 18, 2022. 
 
You asked the Plan to pay for the electrodes. You say that the claim was billed in accordance with the 
enrollee's plan policy allowable, accepted procedure codes, and diagnosis codes according to plan type. The 
Plan denied your request. The Plan says that the Proof of Delivery is not itemized to indicate the specific 
supplies and therefore the billed supply code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid proof of delivery which support medical necessity for the supplies provided in 
this case. Therefore, we decided that the Plan has to pay for the electrodes (A4595) provided on September 18, 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator supplies (electrodes) (A4595) 
provided on September 19, 2022. 
 
You asked the Plan to pay for the electrodes. You say that this claim was billed in accordance with the 
enrollee's insurance policy allowable, accepted procedure codes, and diagnosis codes according to plan type. 
The Plan denied your request. The Plan says the documentation submitted did not sufficiently support the billed 
supply code. 
 
The Plan must follow Medicare rules. Medicare rules say that all durable medical equipment items ordered by 
chiropractors are denied. 
 
 
 
 
 We looked at the file and Medicare rules. Specifically, the record shows that these electrodes were ordered by a 
chiropractor. Based on this information, we decided that Medicare rules for coverage of the electrodes have not 
been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulator supplies 
(electrodes) (A4595) provided on September 19, 2022.
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 requesting Inpatient Rehabilitation Facility (IRF) 
admission for the enrollee, based on medical necessity. The Plan denied your request. The Plan says the 
enrollee does not have complex medical or intensive rehabilitation needs requiring supervision by a 
rehabilitation physician and an intensive and coordinated interdisciplinary team in a resource intensive 
inpatient hospital environment. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360 and 88381 billed for 
January 21, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of 
the PC services when furnished in a different payment locality than the TC. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -26 
modifier to allow for separate PC payment. Therefore, we decided that the Plan does not have to pay for 
procedure codes 88341, 88342, 88360 and 88381 billed for January 21, 2022.