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

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service October 20, 
2022. 
 
You asked the Plan to pay for procedure code 88305. You say that this service was reported correctly. The Plan 
denied your request. The Plan says the code reported is inappropriate for the service provided. 
 
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 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 88305. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the pathology service in question was performed on a 
prostate biopsy specimen; according to the Centers for Medicare and Medicaid Services National Correct 
Coding Initiative policy manual, any and all surgical pathology submitted for prostate biopsy specimens are to be reported with one unit of G0416 rather than 88305. 
 
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 88305 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 88305 billed for date of service October 20, 2022.
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 need an extension of her Skilled Nursing 
Facility days due to needing to get the authorization approved for long term acute care hospital admission. The 
Plan denied your request. The Plan says Skilled Nursing Facility is no longer medically necessary and does not 
meet guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator (E0747). 
 
You asked the Plan to pre-approve an osteogenesis stimulator. 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 follows Medicare rules. Medicare rules say that a non-spinal electrical osteogenesis stimulator 
(E0747) is covered only if certain criteria 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 an osteogenesis stimulator. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not 
have an evidence-based indication for this device. Therefore, the request is deemed not medically reasonable 
and 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 an osteogenesis stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an osteogenesis stimulator (E0747).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant and implant body (D6011, D6010). 
 
You asked the Plan to pre-approve 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 your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service with the Plan's prior 
authorization. Therefore, we decided that the Plan does not have to pre-approve an endosteal implant and 
implant body (D6011, D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat elevator (E2300), electronic connection 
(E2311), expandable controller (E2377), and harness (E2313). 
 
You asked the Plan to pre-approve the seat elevator, electronic connection, expandable controller, and harness. 
You say that the items are medically necessary. The Plan denied your request. The Plan says the power seat 
elevation feature is not primarily medical in nature and the electronic connection, expandable controller, and 
harness re 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 the seat elevator, electronic connection, 
expandable controller, and expandable controller harness. Our reviewer says that the requested items are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the patient's upper 
functional ability is sufficient to control any power options through their own switches. 
 
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 seat elevator, electronic connection, expandable controller, and expandable 
controller harness have not been met. Therefore, we decided that the Plan does not have to pre-approve the seat 
elevator (E2300), electronic connection (E2311), expandable controller (E2377), and harness (E2313).
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 had a stroke and have been to the hospital, acute 
rehabilitation, back to hospital, back to acute rehabilitation, and upon release still unable to live on your own, 
you need admission to a skilled nursing facility. The Plan denied your request. The Plan says your record does 
not show that you require daily skilled nursing or skilled therapy in a SNF setting, services you require are 
called custodial care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ossur Proflex prosthetic foot (L5981, L5986). 
 
You asked the Plan to pre-approve a prosthetic foot. You say that you do not understand why this was denied. 
The Plan denied your request. The Plan says the records do not support K3 functional ambulation. 
 
The Plan follows Medicare rules. Medicare rules say that prosthetic components may be covered when certain 
criteria 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 a prosthetic foot. Our reviewer says that 
the requested prosthetic foot is not medically necessary. Our physician reviewer found the provided 
documentation does not support that the enrollee is a K3 ambulator. The reviewer found that the documentation 
does not indicate that the enrollee's functional needs cannot be adequately met with a lower-level prosthesis. 
Therefore, the reviewer found that the requested prosthetic foot is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a prosthetic foot have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an Ossur Proflex prosthetic foot (L5981, L5986).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 85060 billed for date of service November 
4, 2022. 
 You asked the Plan to pay for procedure code(s) 85060. The Plan denied your request. The Plan says this code 
is included in the facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
Per the Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code(s) 85060. This 
means that no TC billing is recognized because payment for the underlying clinical laboratory test is made to 
the hospital, generally through the Hospital Fee Schedule payment rate. No payment is recognized for CPT 
code 85060 furnished to hospital outpatients or non-hospital patients. Based on this information, we decided 
that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code(s) 85060 billed for date of service November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service October 5, 2022. 
 
You asked the Plan to pay for code 99223. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 99223 is not supported by the medical record because the records 
don't support medical decision making of high complexity. 
 
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 evaluation and management 
of a patient that requires 3 key components.  The 3 key components are a comprehensive history, 
comprehensive examination and medical decision making of high complexity. 
 
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 code 99223. Our reviewer says that code 99223 is not supported by the medical record. Our reviewer found the patient is an 86-year-old female with a medical 
history including hypertension and cardiac disease who admitted to the hospital on October 5, 2022, with 
atypical chest pain. At the time of presentation in the emergency department, she was hemodynamically stable 
and the initial cardiac diagnostic tests were negative for acute ischemia. It was also noted that she had right 
shoulder pain with previous right shoulder surgery. She was called in as a trauma but once the history was 
obtained it was noted she did not have previous trauma. She remained medically stable. The documentation 
available for review does not support the encounter required 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 code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service October 5, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from September 7, 2022, 
to October 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has been billed incorrectly. 
 
The Plan follows Medicare rules. The rules say that -  
 
We reviewed the file and the Medicare rules. We find that the dates on the claim are incorrect. The "through" 
date must be 29 days after the "from" date. Based on this information, we find that the Medicare rules for 
payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for 
the home health services provided from September 7, 2022, to October 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service September 1, 2022. 
 
You asked the Plan to pay for code 99223. You say that code 99223 was billed correctly. The Plan denied your 
request. The Plan says code 99223 is not supported by the medical record. The records don't support a 
comprehensive history or medical decision making of high complexity. 
 
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 evaluation and management 
of a patient that requires 3 key components. The 3 key components are a comprehensive history, 
comprehensive examination and medical decision making of high complexity. 
 
 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 code 99223. Our reviewer says that code 99223 is not 
supported by the medical record. Our reviewer found the patient is a 76-year-old female with a medical history 
including hypertension who was admitted to the hospital on August 31, 2022, after a fall resulted in a fracture 
in the proximal humerus. On September 1, 2022, the patient member was in stable condition and awaiting 
surgical intervention the following day. The documentation available for review does not support the encounter 
required 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 code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service September 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 6, 2022, to 
September 4, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have sent in the required 
NOA several times. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 6, 2022, to 
September 4, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied authorization. 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, ongoing, skilled nursing needs and the enrollee does not have documented skilled 
therapy needs. 
 
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 home health services.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories/features (E2311, E2313, 
E2377). 
 
You asked the Plan to pre-approve the power wheelchair features. The Plan denied your request. The Plan says 
this 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 the power wheelchair features. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee has 3/5 strength in upper extremities bilaterally. Hand 
strength is not specifically addressed. The enrollee has adequate upper extremity strength to manage standard 
power drive switches. The requested features are not medically reasonable and 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 power wheelchair features have not been met. Therefore, we decided that 
the Plan does not have to pre-approve power wheelchair accessories/features (E2311, E2313, E2377).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the services (49655) provided on September 2, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were 
billed without the appropriate modifier. 
 
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. The Plan argues that the services were billed without the appropriate modifier. 
However, the Plan has not provided documentation indicating which modifier is missing/required in this case. 
Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the 
Plan has to pay for the services (49655) provided on September 2, 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 the testing (95921, 95922) provided on September 14, 2022.  
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided medical records and review of the peer-reviewed medical literature do not document 
that use of the testing of autonomic nervous system function has been shown in controlled studies to result in 
long-term health benefits in patients with diabetes and neuropathy with bilateral leg and foot pain. 
 
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 testing (95921) have not been met. 
 
Medicare rules also say that providers must report services correctly. Providers must report services with the 
appropriate CPT code. In this case, we have confirmed that code 95922 is a column II code to column I code 
95921 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the testing (95921, 95922) provided on September 14, 2022.