Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 home health physical therapy visits, 9 home health 
occupational therapist visits. 
 
You asked the Plan to pre-approve home health services. You say that you are appealing the denial of some 
requested visits for the enrollee. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled therapy needs. The enrollee is functioning at a level commiserate with a 
lower level of care (i.e., HEP, outpatient therapy, layperson supervision). Documentation does not support 
approval of the remaining requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 7 home health physical therapy visits, 9 home health occupational therapist visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99205) provided on January 27, 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 99205 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using time for code selection, 60-74 minutes of 
total time is spent on the date of the encounter". 
 
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 99205 is 
not supported by the records provided. Our reviewer found that the medical records submitted do not support a 
high level of medical decision making or total time required to support the billed code. 
 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 (99205) provided on January 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency care (99285) provided on September 25, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says code 99285 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function".  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 99285 is 
not supported by the records provided. Our reviewer found that he medical records provided do not include 
sufficient documentation to validate an "Emergency department visit for the evaluation and management of a 
patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's 
clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical 
decision making of high complexity. Counseling and/or coordination of care with other physicians, other 
qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and 
the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an 
immediate significant threat to life or physiologic function" was performed on September 25, 2022. Therefore, 
this service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency care (99285) provided on September 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network, post-surgical computed 
tomography (CT) scan of the face provided on August 31, 2022. 
 
You asked the Plan to waive the copayment for an in-network, post-surgical computed tomography (CT) scan 
of the face. You say that this was a post surgical scan and should not have a copayment. The provider said the 
same thing. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $130 
copayment for other outpatient diagnostic tests -radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $130 copayment for an in-network, post-surgical computed tomography (CT) 
scan of the face. This item/service falls within the other outpatient diagnostic tests -radiological diagnostic 
services, not including x-rays benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an in-
network, post-surgical computed tomography (CT) scan of the face provided on August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service October 10, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the clinical 
documentation does not support the service 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 find that CPT code 99292 is not supported in the medical record. Specifically, the records do not show that 
critical care service, 99292, was provided by the servicing provider on the date of service at issue. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99292 billed for date of service October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) provided on June 20, 2022. 
 
You asked the Plan to pay for initial observation care (99220). You say that all three key components of 
procedure code 99220 were documented. The Plan denied your request. The Plan says procedure code 99220 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 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 initial observation care (99220). Our reviewer says that 
billing of procedure code 99220 is not supported. Our reviewer found that the documentation does not show 
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 initial observation care (99220) have not been met. Therefore, we decided that 
the Plan does not have to pay for initial observation care (99220) provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing, localized delivery of 
antimicrobial agents, gingival irrigation, and drugs or medicaments dispensed in the office (D9630, D4921, 
D4381, D4342) provided on July 12, 2022, to September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing, localized delivery of antimicrobial agents, gingival irrigation, and drugs or medicaments dispensed in the office (D9630, D4921, D4381, D4342) provided on July 12, 2022, to 
September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223, 99233) provided from September 5, 
2022, to September 11, 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 99223 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". 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 use of codes 99223 
and 99233 is not supported by the records provided. Our reviewer found that for code 99223, the provided 
records in this case do not document a comprehensive history and a comprehensive examination. For code 
99233, the medical visit notes for September 8, 2022, to September 11, 2022, do not show an extensive number 
of diagnoses or management options, or an extensive amount and complexity of data reviewed and high risk of 
complications. 
 
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 (99223, 99233) provided from September 5, 2022, to September 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomographic (CT) colonography 
(code 74261) provided on August 19, 2022. 
 
You asked the Plan to pay for the CT colonography (code 74261). You say that the service was medically 
necessary. The Plan denied your request. The Plan says the requested CT colonography is not medically 
necessary. 
 
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 CT colonography (code 74261). Our 
reviewer says that the requested CT colonography is not considered medically reasonable and necessary in this 
case. Our physician reviewer found this service is typically considered medically necessary and appropriate in 
scenarios where the enrollee is contraindicated to optical colonoscopy or where optical colonoscopy was attempted but incomplete due to a variety of patient-related and technical factors. No records were provided to 
support the medical necessity and appropriateness of CT colonoscopy for the enrollee in lieu of standard-of-
care screening by optical colonoscopy.  
 
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 CT colonography (code 74261) have not been met. Therefore, we decided 
that the Plan does not have to pay for the CT colonography (code 74261) provided on August 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you believe you are eligible for the SSBCI 
benefits. The Plan denied your request. The Plan says you do not meet the criteria to be eligible for SSBCI 
benefits. 
  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. The Plan requested medical records from your provider but did not 
receive any, and without medical records we cannot determine whether you meet the criteria for the SSBCI 
benefits. Based on this information, we decided that there is insufficient information in the record to determine 
if Medicare rules for coverage of the SSBCI benefits have been met. Therefore, we decided that the Plan does 
not have to pre-approve the SSBCI benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat lift mechanism, electric, any type (E0627) and 
lift chair (A9270). 
 
You asked the Plan to pre-approve the lift chair. You say that you want to appeal because you want the chair so 
you can prop your feet up The Plan denied your request. The Plan says the Medicare criteria for medical 
necessity has not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are 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 lift chair. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollees physician has ordered a recliner to address leg edema. The enrollee does not have 
arthritis or neuromuscular disease. The qualifying condition is not met.  
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 lift chair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the seat lift mechanism, electric, any type (E0627) and lift chair (A9270).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 23, 2022, billed with 
codes 81194, 81301, 81455, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
should be covered. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 23, 2022, billed with codes 81194, 81301, 81455, and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 3, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 97010 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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a monitoring feature/device (A9279). 
 
You asked the Plan to pre-approve a monitoring feature/device. You say that this is necessary because you 
have severe breathing issues while sleeping. The Plan denied your request. The Plan says this is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for A9279 are denied as statutorily non-
covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a monitoring feature/device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a monitoring feature/device (A9279).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac contractility modulation (CCM) system. 
 
You asked the Plan to pre-approve a CCM system. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
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 CCM system. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found cardiac contractility modulation (CCM) remains the subject of multiple studies examining long-
term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such 
statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the 
current time, the CCM system would not be considered medically necessary in this enrollee. 
 
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 CCM system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cardiac contractility modulation (CCM) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25 billed for date of service October 
10, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the office visit. The 
Plan denied your request. The Plan says the code is included in the global surgery period for code 20610. 
 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 99212-25 is not supported in the medical record. Specifically, the records provided do 
not show that the office visit was a significant and separately identifiable evaluation service. Visits by the same 
physician on the same day as a minor surgery are included in the payment for the procedure. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99213-25 billed for date of service October 10, 2022.