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

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) provided to the 
enrollee on October 6, 2021. 
 
You asked the Plan to pay for the care. You say that this should be paid for. The Plan denied your request. The 
Plan says the progress notes received fail to meet the required key components when billing this code. 
 
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." 
 
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 care. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the documentation does not support 
the services billed. The progress notes received failed to meet the required key components when billing for 
initial hospital care of high complexity evaluation and management service. Specifically there was not 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 the care have not been met. Therefore, we decided that the Plan does not have to 
pay for initial hospital care (procedure code 99223) provided to the enrollee on October 6, 2021.
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 requested IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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. The enrollee was admitted for a fall, weakness, congestive heart failure, and respiratory failure. Medical problems are stable. 
There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services (procedure code 93922, 93925) provided to 
the enrollee on May 17, 2022. 
 
You asked the Plan to pay for the services. You say that the medical records show that the diagnosis code was 
appropriate for the date of service. The Plan denied your request. The Plan says these services denied because 
they did not include the appropriate primary, first-listed or principal diagnosis. 
 
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 93922: 
 
Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: 
ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, 
Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and 
anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension 
measurement at 1-2 levels) 
 
CPT 93925: 
 
Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 
 
We find that CPT codes 93922 and 93925 is not supported in the medical record. Specifically, they were billed 
with a secondary only diagnosis code as the primary diagnosis code. 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 imaging services (procedure code 93922, 93925) provided to the enrollee on May 17, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four home health skilled nursing visits for the enrollee. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is 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 the visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found that in this case, the 
documentation doesnt support that the enrollee requires additional skilled nursing services  to provide 
treatment that is medically necessary. The enrollee does not require additional skilled nursing services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration.  The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are 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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve four home health skilled nursing visits for the enrollee.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve CMF chemotherapy (cyclophosphamide-methotrexate-
fluorouracil) with pegfilgrastim (Fulphila), dexamethasone and diphenhydramine. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is off-label and not medically supported. 
 
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 the services. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that this CMF 
chemotherapy is Food and Drug Administration (FDA)-approved for the enrollee's diagnosis. The National 
Comprehensive Care Network (NCCN) Guidelines Version 4.2022 Invasive Breast Cancer also supports this 
request. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve CMF chemotherapy (cyclophosphamide-methotrexate-fluorouracil) with pegfilgrastim (Fulphila), 
dexamethasone and diphenhydramine.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services provided on February 4, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the non-emergency ambulance services. You say that you would like retro 
authorization for these services. The Plan denied your request. The Plan says these services were not 
authorized, and authorization is required. 
 
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. 
 Your organization is not a network provider with the Plan. 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 non-emergency ambulance services provided on February 4, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pemetrexed and Bevacizumab-Awwb. 
 
You asked the Plan to pre-approve Pemetrexed and Bevacizumab-Awwb. 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 Pemetrexed and Bevacizumab-Awwb. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found use is not FDA 
approved or supported by major drug compendia or the medical literature. Bevacizumab, in combination with 
chemotherapy (or biologic therapy), is associated with an increased risk of treatment-related mortality; a higher 
risk of fatal adverse events was identified in a meta-analysis of 16 trials in which bevacizumab was used for the 
treatment of various cancers (breast cancer, colorectal cancer, NSCLC, pancreatic cancer, prostate cancer, and 
renal cell cancer) and compared to chemotherapy alone. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pemetrexed and Bevacizumab-Awwb have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Pemetrexed and Bevacizumab-Awwb.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis (D1110) provided on March 1, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the amount you were 
reimbursed for the cleaning. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for prophylaxis (D1110) provided on March 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) supplies billed for date 
of service November 18, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that you have provided proof of delivery 
documentation to support payment. The Plan denied your request. The Plan says the documentation submitted 
does not support the date of service billed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for medical supplies, the date of service billed 
should either be the date of delivery or the date of shipping of the item(s).  In this case, you billed date of 
service November 19, 2021. However, the documentation you submitted shows that the CGM supplies were 
shipped on November 8, 2021, and delivered on November 10, 2021.  Neither of these dates matches the date 
you have billed as the date of service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
continuous glucose monitor (CGM) supplies billed for date of service November 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for inpatient hospital services provided from February 1, 
2022, to February 4, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that this hospitalization 
was for COVID-19, so there should be no cost sharing. The Plan denied your request. The Plan says that it 
failed to render a decision within the required timeframe. 
 
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 completely failed to address your assertion that this 
hospitalization was for COVID-19 treatment.  According to the Plan's own website, "Medicare Advantage 
members will have no copays, deductibles or coinsurance for covered services for treatment of active, 
confirmed cases of COVID-19."  The Plan has provided no evidence that this hospitalization was not for 
treatment of COVID-19. The burden is on the Plan to prove that its assessment of cost sharing is correct, and it 
has failed to do so in this case. Therefore, we decided that the Plan has to waive the copayment for inpatient 
hospital services provided from February 1, 2022, to February 4, 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 surgical assistant services provided by a certified surgical 
first assistant (CSFA) on January 12, 2022. 
 
You asked the Plan to pay for the CSFA services. You say that these services were medically necessary, and 
this claim should be paid. The Plan denied your request. The Plan says CSFAs are not eligible providers. On 
the date of service, the CSFA was not yet a physician's assistant and therefore does not qualify for coverage. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
by a certified surgical first assistant (CSFA) on January 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99238 billed for date of service May 19, 2022. 
 
You asked the Plan to pay for code 99238. You say that the patient had two separate admissions, so this claim 
should be paid. The Plan denied your request. The Plan says that code 99238 can only be billed once per 
admission. 
 
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's sole rationale for denial is that 99238 is only paid once 
per admission.  That may be true, however, it appears as though the Plan has ignored the evidence in the 
medical records provided.  The records provided clearly show that the patient had two separate admissions at 
different hospitals.  The patient was treated at one hospital, discharged on May 18, 2022, then transferred to a 
second hospital.  Following treatment at the second hospital, the patient was then discharged from the second 
hospital on May 19, 2022.  Because the patient had two separate admissions (and the Plan has provided no 
evidence to the contrary), we find that the Plan has not supported its denial in this case. Therefore, we decided 
that the Plan has to pay for code 99238 billed for date of service May 19, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 lab services provided on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 5, 2022 billed with 
codes 81994, 81301, 81455, 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid. The Plan denied your 
request. The Plan says this was not reported correctly. 
 
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 
April 5, 2022 billed with codes 81994, 81301, 81455, 81479.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rhythm electrocardiogram (procedure code 93042) 
provided to the enrollee on May 13, 2022. 
 
You asked the Plan to pay for the services. You say that the patient presented to the emergency center for 
services which as evidenced by the plan processing a payment has already been deemed as medically 
necessary. The Plan denied your request. The Plan says the documentation does not support a separate and 
distinct procedure. 
 
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 93042 is "Rhythm ECG, 1-3 leads; interpretation and 
report only." 
 
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 CPT codes 99285 and 93010 were 
billed on the same claim and processed for payment by the plan. The documentation does not provide a separate distinctly identifiable signed written report. 
 
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 a rhythm electrocardiogram (procedure code 93042) provided to the enrollee on May 13, 2022.