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

 
We decided that the Plan does not have to pay for initial nursing facility care (99306) provided on September 
20, 2022. 
 
You asked the Plan to pay for initial nursing facility care (99306). You say that the medical records prove the 
necessity of the services performed. The Plan denied your request. The Plan says the medical records submitted 
do not support a comprehensive history, a comprehensive examination and 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 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 initial nursing facility care (99306). Our reviewer says that 
the documentation does not support procedure code 99306 based on the key components in the code 
description. Our reviewer found the submitted medical records do not support a comprehensive history, a 
comprehensive examination 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 initial nursing facility care (99306) have not been met. Therefore, we decided 
that the Plan does not have to pay for initial nursing facility care (99306) provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skin tag removal, and the unadministered vaccine 
provided on December 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the skin tag removal and the unadministered vaccine. You say that you did not 
know what the cost of these services would be. The Plan denied your request. The Plan says you must receive 
your care from a network provider. 

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. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 the skin tag removal, and the unadministered 
vaccine provided on December 5, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for dental services provided on February 17, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the services paid for by your 
insurance. The Plan denied your request. The Plan says that the services do not meet medical necessary criteria. 
 
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 did not send us clear medical records. Without digital x-
rays we cannot determine if the requested service is medically necessary. Therefore, we decided that the Plan 
has to pay for dental services provided on February 17, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply code A0382 billed for date of service January 17, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services are considered part of the general ambulance payment. 

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 A0382 is basic life support routine disposable supplies.  
We find that payment for disposable supplies is not separately payable. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for supply code A0382 billed for date of service January 17, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that your condition is deteriorating fast and need help as 
soon as possible. The Plan denied your request. The Plan says a SNF admission is not medically necessary, and 
your needs can be met at a lower level of 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 that 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 or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94640 billed for date of service December 
14, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code is covered by the fee schedule. The 
Plan denied your request. The Plan says the code is not separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 94640 has a status indicator of Q1. This code is packaged when billed on the same 
claim as a code assigned status indicator V, such as code 99285. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 94640 billed for date of service December 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee's needs can be met at an alternate level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does have complex functional impairments. However, the enrollee 
does not have any active medical comorbidities and would not be expected to require continued inpatient 
hospitalization with close medical supervision in an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings that have been 
ordered by your vein doctor have been denied. You also say that you would like to have your Medicare 
insurance cover the $62.50 per pair of stockings, so you don't have to pay for these out of pocket. The Plan 
denied your request.  
 The Plan says you do not have a qualifying wound for coverage of compression stockings. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the exploration of spinal fusion (22830). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says neither Medicare nor the enrollee's Medicare Advantage Health Plan covers 
spinal fusion exploration when it is provided at the same time and in the same spinal region as the enrollee's 
requested spinal surgery. 
 
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested exploration of fusion would not be considered a separate procedure from the 
approved procedure. It is noted common practice to explore the surgical field while performing the approved 
procedure. There are limited large-scale, long-term references showing the requested surgery, would be billable 
as a separate procedure, in this clinical setting. No compelling rationale is presented, or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
exploration of spinal fusion (CPT 22830), in this case, 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the exploration of spinal fusion (22830).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93923 billed for date of service September 3, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the services. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 93923 is complete bilateral noninvasive physiologic 
studies of upper or lower extremity arteries, 3 or more levels (e.g., for lower extremity: ankle/brachial indices 
at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements 
with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at 
distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or 
more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus 
segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with 
provocative functional maneuvers (e.g., measurements with postural provocative tests, or measurements with 
reactive hyperemia). 
 
We find that CPT code 93923 is not supported in the medical record. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 93923 billed for date of service September 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item should be covered. The 
Plan denied your request. The Plan says a pneumatic compression device is not covered for preventative 
services during or after surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
July 19, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says procedure codes 99100 and 99140 are 
considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
July 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 40 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 40 routine transportation trips. You say that you need 
transportation to your medical appointments. The Plan denied your request. The Plan says this request will 
exceed the maximum number of transportation trips allowed per year. 
 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 48 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 40 routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223-25 billed for date of service October 14, 2022. 
 
You asked the Plan to pay for code 99223-25. You say that code 99223 was billed with modifier 25, so that 
should unbundle it from other procedures performed. The Plan denied your request. The Plan says the use of 
the 25 modifier to allow for separate payment of code 99223 is not supported by the medical record. This code 
is included in the global day period of codes 92937, 93455, and 99152. The documentation does not support a 
does not support a significant, separately identifiable evaluation and management service to support the use of 
the 25 modifier. In addition, this initial hospital care evaluation and management code requires a 
comprehensive history, a comprehensive examination and medical decision making of high complexity. 
However, the medical records submitted don't support a comprehensive history and a comprehensive 
examination. Therefore, the billed current procedural terminology (CPT) code cannot be verified. 
 
The Plan follows Medicare rules. Medicare rules say that modifier 25 is used to identify a significant, 
separately identifiable evaluation and management service by the same physician on the same day of the 
procedure or other service.  
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 code 99223-25. Our reviewer says that the 
use of the 25 modifier to allow for separate payment of code 99223 is not supported. Our physician reviewer 
found the provider performed an evaluation and management service on same date of service as heart 
catheterization and intervention procedure. The evaluation and management service provided is directly related 
to the procedures performed, and therefore would be included in the global period. Therefore, modifier 25 
cannot be verified, as the service was not a distinct procedural service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99223-25 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223-25 billed for date of service October 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87634 billed for date of service November 7, 
2022. 
 
You asked the Plan to pay for procedure code 87634. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 87634 is bundled into 
payment for code 87798. 
 
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 87634 
is a column II code to column I code 87798. This claim has not been billed with an appropriate modifier to 
bypass the edit. The records do not support that the procedure or service was distinct from other services 
performed, making the -59 modifier not supported. 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 code 87634 billed 
for date of service November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a vacuum pump (L5781). 
 
You asked the Plan to pre-approve a vacuum pump. You say that your prosthetic is not staying on/secure at this 
time, and you could end up with injuries due to the current instability of your current prosthesis. The Plan 
denied your request. The Plan says that experimental and investigational items are not covered by Medicare. 
 
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 records do not support the Plan's denial in this case. This means that the 
Plan has not provided a valid reason for denying payment of a vacuum pump. Specifically, medical records 
were not provided, and there is no documentation showing the Plan attempted to obtain any medical records. It 
is the burden of the Plan to substantiate their denial with evidence. In this case, the denial has not been 
substantiated. Therefore, we decided that the Plan has to pre-approve a vacuum pump (L5781).  
 
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.