Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 9, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xolair. 
 
You asked the Plan to pre-approve Xolair. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Xolair. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Xolair is medically reasonable and necessary or safe and effective for 
the 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 Xolair have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Xolair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) and appliance 
provided on September 30, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) and appliance provided on September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on November 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was not an 
inpatient. 
 
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 find that CPT code 99233 is not supported in the medical record. Specifically, the records do not show that 
the enrollee was under inpatient status on the date of service in question. As such, it is inappropriate to bill and 
inpatient evaluation and management code for the services provided. 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 (99233) provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care (99220) provided on September 27, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was not 
under observation. 
 
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 find that CPT code 99220 is not supported in the medical record. Specifically, this code is used for 
observation care. The record do not show that the enrollee was under observation when the services were 
provided. 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 observation care (99220) provided on 
September 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 2, 2021. 
 
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 claim for this molecular pathology testing did not include the required unique 
identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
November 2, 2021.
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 July 9, 2022, to July 11, 2022. 
 
You asked the Plan to pay for the esrvices. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do 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 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 esrvices. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the physical examination is not 
detailed, and there was no complex decision making. The enrollee was stable and the symptoms resolved. The 
physical exam did not include details in the head and neck and was limited in scope. There was no evaluation 
of the vascular tree, and the neurological exam was not detailed. In general, a number of details were missing 
from the physical exam. The 7/10 progress note was brief without details or complexity in decision making. 
The 7/11 discharge note does not show complexity, care coordination, or detailed history. 
 
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 esrvices have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99233) rendered from July 9, 2022, to July 11, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (99215) provided on November 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this code is 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, the CPT Code Manual definition of 
code 99215 is "Office or other outpatient visit for the evaluation and management of an established patient, 
which requires a medically appropriate history and/or examination and high level of medical decision making. 
When using time for code selection, 40-54 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 99215 is 
supported by the records provided. Our reviewer found that with coding guidelines in 2022, time-based coding 
is acceptable, and the documentation states the patient was seen for 40 minutes face-to-face. This meets the 
requirements for code 99215. 
 
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 (99215) provided on November 8, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that without IRF services your recovery will take 
significantly longer. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom-fabricated bilateral knee orthosis (L1834), and 
suspension sleeves (L2397) provided on March 8, 2022. 
 
You asked the Plan to pay for the DME. You say that the DME is medically necessary. The Plan denied your 
request. The Plan says the DME is not medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the DME. Our physician reviewer found the 
clinical documentation provided does not support the need for knee orthoses and suspension sleeves. The 
enrollee has a medical history of knee osteoarthritis and gait instability. However, there is limited 
documentation regarding the physical examination of the enrollee's knee joints, including range of motion and 
motor strength. There is no noted contracture, instability of the knee joints or recent injury or surgery of the 
knee joints. The enrollee has knee osteoarthritis, but this does not necessarily require knee orthoses and 
suspension sleeves. Therefore, the knee orthoses (L1834) and suspension sleeves (L2397) were 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 the DME have not been met. Therefore, we decided that the Plan does not have 
to pay for the custom-fabricated bilateral knee orthosis (L1834), and suspension sleeves (L2397) provided on 
March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR (polymerase chain reaction) panel provided on 
June 27, 2022, and billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87640, 
87641, 87651, 87653, 87661 and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine PCR panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the urine PCR (polymerase chain reaction) panel provided on June 27, 2022, and billed with codes 87481, 
87491, 87496, 87500, 87511, 87529, 87532, 87563, 87591, 87640, 87641, 87651, 87653, 87661 and 87798.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 99223 and 99233 billed for dates of service July 23, 
2022, and July 24, 2022. 
 
You asked the Plan to pay for codes 99223 and 99233. You say that this claim should be paid. 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 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 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 codes 99223 and 99233. Our reviewer says that codes 99233 
and 99233 are not supported by the medical records. Our reviewer found in relation to code 99223, the physical 
examination was not comprehensive, so the code was not supported.  In relation to code 99233, the interval 
history was not detailed and the medical decision making shows no significant changes and is therefore 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 codes 99223 and 99233 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 99223 and 99233 billed for dates of service July 23, 2022, and July 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of nasal vestibular stenosis (30465). 
 
You asked the Plan to pre-approve nasal surgery. You say that you cannot breathe, and your nose is running 
profusely. You can stop breathing anytime without advanced notice. The Plan denied your request. The Plan 
says the request does not meet the Medicare or Plan coverage 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 nasal surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a diagnosis of nasal congestion, stenosis of nasal valve, chronic rhinitis, chronic 
maxillary sinusitis, and anterior epistaxis. Based on the medical records provided, there is no documentation 
that the repair of nasal vestibular stenosis at issue in this case meets all Medicare criteria for medically 
reasonable and necessary for you. Provided records in this case do not document any of your physical 
examination to confirm the diagnosis and to confirm your anatomy is amenable to the requested surgical 
procedure. As summarized in Up to Date: "The physical examination of the nose is of primary importance in 
identifying or confirming the cause of nasal obstruction. Most of the underlying causes of nasal obstruction can 
be determined based on a thorough examination of the nose, nasal cavity, and the nasopharynx." 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nasal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repair of nasal vestibular stenosis (30465).
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. There is not a reasonable expectation that this 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you feel that denying you admission to a nursing 
home is medical neglect and is against the law. The Plan denied your request. The Plan says a SNF admission 
is not medically necessary. 
 
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 the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. 
 
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 skilled nursing facility (SNF) care.