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

 
We decided that the Plan does not have to pay for procedure codes 99220 and 99497 rendered on June 5, 2022. 
 
You asked the Plan to pay for the services. You say that this should be reconsidered and reprocessed for 
payment. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99220 and 
99497 remain 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 the denied codes is: 
 
CPT 99220: 
 
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 
 
CPT 99497: 
 
Advance care planning including the explanation and discussion of advance directives such as standard forms 
(with completion of such forms, when performed), by the physician or other qualified health care professional; 
first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 99220, the 
records submitted did not support that a comprehensive history was done. In terms of CPT 99497, the 
documentation submitted did not support a significant, separately identifiable evaluation and management 
service to support the use of this code with the 25 modifier. CPT 99497 should not be separately reimbursed. 
 
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 procedure codes 99220 and 99497 rendered on June 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95911 and 95955 rendered on July 18, 
2022. 
 
You asked the Plan to pay for the services. You say that you sent medical records for review. The Plan denied 
your request. The Plan says the requested service codes are not substantiated by the clinical documentation in 
the medical records submitted for review. 
 
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 95911: 
 
Nerve conduction studies; 9-10 studies 
 
CPT 95955: 
 
Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 95911, there was 
no documentation provided a nerve conduction study (NCS) was done. The technical report made no reference 
to performance of NCS. The member otherwise only had pedicle screw testing done which is otherwise 
reflected in (inherent to) the performance of electromyography (EMG) recording/testing. Consequently, this 
code cannot be said to be supported by the records. In terms of CPT 95955, the records only supported use of a 
two channel EEG recording. This falls well below the current technical standards for performance of an EEG. 
A 2 channel EEG is otherwise not of any clinical or diagnostic utility. In as much this service as coded for 
cannot be said to have been supported by the records. 
 
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 procedure codes 95911 and 95955 rendered on July 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services rendered from May 10, 2021, to 
May 11, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting that the denied days 
are processed for immediate payment. The Plan denied your request. The Plan says inpatient care rather than 
outpatient care is required only if the beneficiary's medical condition, safety, or health would be 
significantly and directly threatened if care was provided in a less intensive setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the review has determined that the record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier emergency care and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services rendered from May 10, 2021, to May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95957 provided on March 15, 2022. 
 
You asked the Plan to pay for procedure code 95957. You say that the medical records support the billing of 
code 95957. The Plan denied your request. The Plan says the medical records do not support the billing of code 
95957. 
 
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 95957 is Digital analysis of electroencephalogram (EEG) 
(eg, for epileptic spike analysis). 
 
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 procedure code 95957. Our reviewer says that the medical 
records do not support the billing of code 95957. Our reviewer found the record states that the 
electroencephalogram (EEG) was performed with XLTek spike wave discharge detection software. According to coding rules, this is included in 95700 and is not separately reportable with 95957. Coding guidelines do not 
allow 95957 to be reported when automated spike detection software is utilized. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95957 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95957 provided on March 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient skilled nursing facility (SNF) care 
provided from May 2, 2022, through June 9, 2022. 
 
You asked the Plan to pay for the SNF care. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the inpatient skilled nursing facility care 
provided was 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 pay for the SNF care. Our reviewer says that the 
SNF care provided was not medically reasonable and necessary based on Medicare guidelines. Our physician 
reviewer found that the enrollee did not require skilled nursing or skilled therapy services on a daily basis. 
Additionally, as a practical matter, the enrollee did not require the services on an inpatient basis, only in a 
skilled nursing facility setting. The services provided in the nursing facility appear custodial in this case with 
part time therapy treatment provided. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the continued inpatient skilled nursing facility (SNF) care provided from May 2, 2022, through 
June 9, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Lucentis (J2778). 
 
You asked the Plan to pre-approve Lucentis. You say that the requested drug is a medical necessity for the 
enrollee and not a new start. The Plan denied your request. The Plan says that step-therapy rules for coverage 
of the requested drug have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Lucentis. Our reviewer says that the 
requested drug is medically reasonable and necessary in this case. Our physician reviewer found that step-
therapy rules may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are 
not actively receiving the affected medication. In this case, the enrollee has been receiving Lucentis and 
tolerating it since 2021; step-therapy rules do not apply in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have been met. Therefore, we decided that the Plan has to pre-approve 
treatment with Lucentis (J2778).  
 
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 subsequent hospital care (procedure code 99233) rendered on 
May 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of code 99233 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the evaluation and management 
code billed requires a detailed interval history, a detailed examination and medical decision making of high complexity. However, the medical records submitted did not support a detailed interval history and 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (procedure code 99233) rendered on May 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 75710-59, 37184-LT and 36247-RT, billed 
for date of service November 3, 2022. 
 You asked the Plan to pay for the billed codes. You say that the claim was billed correctly and should be paid. 
The Plan denied your request. The Plan says payment for code 75710-59 is bundled into payment for code 
37211. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 75710 
is a column II code to column I code 37211. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 75710-59, 37184-LT and 36247-RT, billed for 
date of service November 3, 2022. We also decided that the plan does not have to pay for codes 37184-LT and 
36247-RT as these codes were not supported by the documentation submitted.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (procedure code 99306) provided 
to the enrollee on June 9, 2022. 
 
You asked the Plan to pay for the services. You say that you submitted medical records for review. The Plan 
denied your request. The Plan says Current Procedural Terminology (CPT) code 99306-25 (1 unit) remains not 
supported, as 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 99306 is "Initial nursing facility 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, 45 minutes are spent at the bedside and on the patient's facility floor 
or unit." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the review has determined that 
the records did not support there was a comprehensive history. The records did not support that there was a 
comprehensive exam. The records did not support that there was 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial nursing facility care (procedure code 99306) provided to the enrollee on June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx (0239U) provided April 27, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that the FoundationOne Liquid CDx is a 
medically necessary laboratory test for patients with advanced state, solid tumor cancers who have decided to 
seek further treatment. The Plan denied your request. The Plan says documentation does not support that the 
services rendered were medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Additional records were needed from the provider to support the necessity of the services. The Plan made 
multiple attempts to obtain the needed records from the provider without success. Therefore, we decided that 
the Plan does not have to pay for the FoundationOne Liquid CDx (0239U) provided April 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick. 
 
You asked the Plan to pre-approve Repatha Sureclick. You say that this request is for the patient under their 
pharmacy benefit. The Plan denied your request. The Plan says self-administered medication does not fall 
under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick.  
 
  Benefits for Repatha Sureclick may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on November 22, 2022. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI). You say that you are being 
over charged for this service. 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 $175 
copayment for diagnostic imaging. 
 
You have been asked to pay a $175 copayment for magnetic resonance imaging (MRI). This item/service falls 
within the diagnostic imaging 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 magnetic 
resonance imaging (MRI) provided on November 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for items identified with codes K0108 and K0739 provided on 
May 3, 2022. 
 
You asked the Plan to pay for items identified with codes K0108 and K0739. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the items rendered are not payable as 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 codes K0108 and K0739 are not supported in the medical record. Specifically, these codes were 
billed with a primary diagnosis code that is a manifestation code. Manifestation codes cannot be billed 
as first listed diagnosis on claim, regardless of assigned diagnosis pointers. Based on this information, we 
decided that Medicare rules for coverage of items identified with codes K0108 and K0739 have not been met. Therefore, we decided that the Plan does not have to pay for items identified with codes K0108 and K0739 
provided on May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home ventilator (E0467), oxygen concentrator (E1390), 
delivery and set up (A9901), and connection kit (E1399) purchased on November 15, 2021. 
 
You asked the Plan to pay for the home ventilator, oxygen concentrator, delivery and set up, and connection 
kit. You say that the items should be covered. The Plan denied your request. The Plan says the items were 
purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the home ventilator (E0467), oxygen 
concentrator (E1390), delivery and set up (A9901), and connection kit (E1399) purchased on November 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination of the chest (code 71045-26) 
provided on September 15, 2022. 
 
You asked the Plan to pay for the radiologic examination of the chest. You say that the claim is not a duplicate. 
The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was 
correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on October 17, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this information, we decided that the Medicare rules for the radiologic examination of the chest have not been met. 
Therefore, we decided that the Plan does not have to pay for a radiologic examination of the chest  
(code 71045-26) provided on September 15, 2022.