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

 
We decided that the Plan does not have to pay for procedure codes 99212-25 and 11721 Q8 provided 
September 14, 2023. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says CPT code 99212-25 remains not supported, as this code is included in the global day 
period of CPT code 11721. The Plan states the documentation submitted does not support a significant, 
separately identifiable evaluation and management service to support the use of modifier 25. The Plan states 
11721-Q8 is not supported because the medical records submitted indicate the debridement of nail(s) by any 
method(s); 6 or more was ordered; however, the documentation does not support that debridement was 
performed on the billed date of service. 
 
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 99212 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 straightforward medical decision making. When using time for code selection, 10-19 minutes of total time 
is spent on the date of the encounter. The definition of code 11721 is debridement of nail(s) by any method(s); 
6 or more. 
 
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 found for code 99212, the 
documentation submitted was reviewed and does not meet criteria. The provider reported procedure code with 
appended modifier 25 significant, separately identifiable evaluation and management (E/M) service above and 
beyond that associated with another procedure or service being reported by the same physician or other 
qualified health care professional (QHP) on the same date to bypass NCCI Edit with nail debridement service; 
however, the procedure report does not include documentation of a significant, evaluation and management 
service above and beyond the nail debridement service provided. For code 11721, the documentation submitted 
was reviewed and does not meet criteria. The procedure report documents CPT code; however, there is 
insufficient documentation to confirm service was performed and therefore, cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99212-25 and 11721 Q8 provided September 14, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on September 28, 2023, billed with 
procedure code 99291-25. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that documentation does not support the billed 
code. 
 
The Plan follows Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. 
 
We asked our coding 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 practitioner services provided. Our 
reviewer says that documentation does support the billed code. Our physician reviewer found that the record 
states that critical care was performed and was not part of another service. 
 
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 practitioner services provided have been met. Therefore, we decided that the 
Plan has to pay for practitioner services provided on September 28, 2023, billed with procedure code 99291-25.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ingrezza capsule. 
 
You asked the Plan to pre-approve Ingrezza. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the medication is not covered as a medical benefit under 
the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Ingrezza 
capsule.  
 
Benefits for Ingrezza 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 10 routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you have additional appointments for the 
rest of the year and have no other means of getting to them. The Plan denied your request. The Plan says you 
have exhausted this benefit for 2023. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 10 routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Barostim Neo system (0266T). 
 
You asked the Plan to pre-approve a Barostim Neo system. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Barostim Neo system. Our reviewer 
says that the requested service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there remains an absence of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of Barostim Neo in patient management. 
 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 Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of a Barostim Neo system (0266T).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11 home health skilled nursing visits. 
 You asked the Plan to pre-approve home health services. You say that the services are necessary. 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 clinical 
documentation shows that the enrollee has had the current right lower limb wound since October of 2020 and 
currently is requiring cleansing with application of betadine to wound bed. Clinical documentation does not 
specify any acute clinical status, medication or plan of care change thus the records do not show that 11 
additional skilled nursing visits are required to effectively provide treatment, care, and/or services in order to 
improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's 
condition and/or prevent deterioration. It would not require the skilled service of a skilled nurse to apply 
betadine and cleanse a simple wound that is documented. 
 
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 11 home health skilled nursing visits.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a hallux rigidus correction with cheilectomy (28291). 
 
You asked the Plan to pre-approve a hallux rigidus correction with cheilectomy. You say that the requested 
services are a medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested 
services are experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pre-approve a hallux rigidus correction with 
cheilectomy. Our reviewer says that the requested services are considered medically reasonable and necessary 
in this case. Our physician reviewer found that in this case, given the pain to the first metatarsal phalangeal 
joint (MPJ) that is noted during the clinical exam, and the imaging of the first MPJ left side, which 
demonstrates advanced arthritic changes with osteophyte formation, the requested hallux rigidus correction 
with cheilectomy and HemiCAP implant is medically reasonable and necessary. Standard of care treatments for 
hallux rigidus include cheilectomy, arthrodesis, total MPJ implant and hemi implant. All of the aforementioned 
procedures are considered standard 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 a hallux rigidus correction with cheilectomy have been met. Therefore, we 
decided that the Plan has to pre-approve a hallux rigidus correction with cheilectomy (28291).  
 
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: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit (procedure 99285) provided on March 
1, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says that the 
records do not support the services at issue in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99285 is emergency department visit for the evaluation and management of a patient, which requires a 
medically appropriate history and/or examination and high level of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is supported by the medical records. Our reviewer found 
documentation show an appropriate history and physical exam was performed. The medical records support a 
high level of medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have been met. Therefore, we 
decided that the Plan has to pay for an emergency department visit (procedure 99285) provided on March 1, 
2023.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on March 2, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the medical records do not support a high level of medical decision making. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on March 2, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0483 provided on July 18, 2023. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. Medicare rules also say that providers must report services correctly. Providers must report services 
with the appropriate CPT code. 
 
The CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug classes, including 
metabolite(s) if performed.  
 The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the citation the Plan used in their decision to deny services is not 
consistent with what Medicare intended for these drug codes. Therefore, we decided that the Plan has to pay for 
procedure code G0483 provided on July 18, 2023.  
 
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 office visit (99205) provided on September 1, 2023. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says this provider has opted-out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office 
visit (99205) provided on September 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no documentation provided indicating that the enrollee has medical 
necessity for an admission to an LTACH. The enrollee is receiving appropriate care at the present acute care 
facility. There does appear to be reasonable participation in therapy however, the enrollee does not have active 
medical conditions that would require treatment only in an LTACH and not in a lower level of care. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where they are currently receiving care. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37225 billed for date of service August 24, 
2023.  
 You asked the Plan to pay for procedure code 37225. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 37225 is 1. The MAI value for this code is 2. The Plan has documented 
that you billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare 
rules for coverage of procedure code 37225 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 37225 billed for date of service August 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that the drug is medically necessary to treat the enrollee's 
condition. The Plan denied your request. The Plan says the drug requested does not meet the necessary 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  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 Opdivo. Our reviewer says that the 
requested drug does not meet the criteria necessary to be approved. Our physician reviewer found the requested 
use for Opdivo is not FDA-approved for the enrollee's diagnosis and is not supported by one of the major drug 
compendia or by clinical research. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing billed for date of service October 4, 2023. 
 
You asked the Plan to pay for the billed testing. The Plan denied your request. The Plan says one code must be 
submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
 The panel testing was billed using codes 87500, 87641, 87798, 87491, 87496, 87529, 87532, 87563, 87591, 
87481, 87651, 87653, and G0452. We looked at the file and Medicare rules. The documentation supports that 
this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple 
methodologies, or multiple kits were used in this case. As such, a single code with one unit of service should be 
used. Based on this information, we decided that Medicare rules for coverage of the testing panel have not been 
met. Therefore, we decided that the Plan does not have to pay for the panel testing billed for date of service 
October 4, 2023.