Persius/hicric huggingface dataset:
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 the enrollee cannot be safely discharged home. They 
live alone and cannot take care of themselves. The Plan denied your request. The Plan says the request is 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 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 the enrollee does not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee does have skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not 
require daily skilled nursing and/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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on April 4, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on April 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies billed with code A4222 for date of service 
February 24, 2023. 
 
You asked the Plan to pay for the supplies billed with code A4222. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services 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 CPT code A4222 is not payable as billed. Specifically, this code was not billed with the KX 
modifier as required. Based on this information, we decided that Medicare rules for coverage of the supplies 
billed with code A4222 have not been met. Therefore, we decided that the Plan does not have to pay for the 
supplies billed with code A4222 for date of service February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4222 billed for date of service April 17, 
2023. 
 
You asked the Plan to pay for procedure code A4222. You say that that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says procedure code A4222 is not covered.  
 
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 code A4222 has a status indicator of X on the Physician Fee Schedule. This means that 
procedure code A4222 is not covered. Based on this information, we decided that Medicare rules for coverage 
of procedure code A4222 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code A4222 billed for date of service April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy administration billed with code 96401 for date 
of service April 17, 2023. 
 
You asked the Plan to pay for code 96401. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed are 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 code 96401 is chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic. 
 
We find that CPT code 96401 is not supported in the medical record. Specifically, the documentation shows 
that Prolia was injected. Prolia is not covered a chemo/complex drug. This means the medical records do not support chemotherapy administration. Based on this information, we decided that Medicare rules for coverage 
of code 96401 have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy 
administration billed with code 96401 for date of service April 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 provided on July 22, 2022. 
 
You asked the Plan to pay for procedure code 87798. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are 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 code 87798 is Infectious agent detection by nucleic acid (DNA 
or RNA), not otherwise specified; amplified probe technique, each organism. 
 
We find that CPT code 87798 is not supported in the medical record. Specifically, this code is a not otherwise 
specified code, and the documentation does not contain a complete description of the not otherwise specified 
code. Based on this information, we decided that Medicare rules for coverage of procedure code 87798 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 87798 provided on 
July 22, 2022.
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 the enrollee is currently a fall risk and requires 
direct care to improve their strength and mobility. The Plan denied your request. The Plan says the enrollee no 
longer had skilled nursing facility needs.  
 
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 the enrollee did not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95910 billed for date of service January 27, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the billed code is 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 code 95910 is nerve conduction studies; 7-8 studies. We find 
that CPT code 95910 is not supported in the medical record. The records show that pedicle screw stimulation 
was provided. 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 95910 billed 
for date of service January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 3, 2023, billed with 
procedure code 99232. 
 
You asked the Plan to pay for the practitioner services provided. You say that that the claim is billed correctly 
and should be paid. The Plan denied your request. The Plan says documentation does not support the billed 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded.  
We find that CPT code 99232 is not supported in the medical record. Specifically, the documentation provided 
does not include the actual date of service that the service was rendered. Based on this information, we decided 
that Medicare rules for coverage of the practitioner services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for practitioner services provided on May 3, 2023, billed with procedure 
code 99232.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service May 3, 2023, 
to May 8, 2023.  
 
You asked the Plan to pay for procedure code 99232. You say that this code is not a duplicate charge. The Plan 
denied your request. The Plan says payment for code 99232 is bundled into payment for code 99238. 
 
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 99232 
is a column II code to column I code 99238 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 procedure code 99232 billed for date of service May 3, 2023, to May 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 25, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says their initial decision to deny payment was correct. 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 office visit provided on May 25, 2023, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 88305 for date of service April 13, 2023. 
 You asked the Plan to pay for code 88305. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the diagnosis code at issue is not appropriate as a primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code R13.1. This code 
is not an appropriate primary diagnosis as the code has a Code first note indicating to code the underlying 
condition first. Based on this information, we decided that Medicare rules for payment of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for code 88305 for date of service April 13, 
2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99232 
billed for date of service May 5, 2023. 
 
You asked the Plan to pay for 99232. You say that 99232 should be covered because the enrollee had multiple 
evaluation and management services on the same date by different providers with different specialties. The 
Plan denied your request. The Plan says 99232 is denied because another evaluation and management service 
was billed for the same date, with the same diagnosis, by a physician of the same specialty, in the same billing 
group. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
service is provided on the same day to the same enrollee by more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and 
management services are for unrelated problems.  
 
We looked at the file and Medicare rules. We confirmed that 99232 performed on May 5, 2023, was billed by a 
provider in the same group with the same specialty and taxonomy code as another evaluation and management 
service billed for the same date. Records also document that 99232 was billed with the same diagnosis codes as 
the other evaluation and management service billed by the same group, indicating 99232 was not regarding an 
unrelated problem. Based on this information, we decided that Medicare rules for coverage of 99232 have not 
been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management services 
coded as 99232 billed for date of service May 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for additional panoramic x-rays and 2D oral/facial photographic
image (D0350) provided on May 23, 2023.

You asked the Plan to pay for 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. Coverage for the 2D oral/facial photographic image denied correctly as this service
does not fall within your dental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's 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 May 23, 2023 (D0330).
Additionally, coverage for the 2D oral/facial photographic image denied correctly as this service does not fall
within your dental benefits. Therefore, we decided that the Plan does not have to pay for additional panoramic
x-rays and 2D oral/facial photographic image (D0350) provided on May 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 for date of service March 10, 2023. 
 
You asked the Plan to pay for procedure code 99223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded. 
 
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 procedure code 99223. Our reviewer says 
that the documentation does not support that the code billed is supported. Our reviewer found the enrollee 
presented to the Emergency Department with shortness of breath and dyspnea on exertion. The enrollee was 
evaluated and admitted. The documentation does not support medical decision making of high complexity or 
75 minutes spent. Therefore, this code is not supported. 
 
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 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 for date of service March 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 19, 2022, 
to December 29, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA. 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 December 19, 2022, to 
December 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing provided on March 29, 2023. 
 
You asked the Plan to pay for the Tempus xF testing. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the test provided is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Tempus xF testing is non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the test at issue is specifically not 
covered. Based on this information, we decided that Medicare rules for coverage of the Tempus xF testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF testing provided on 
March 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation to build your 
mobility skills back up. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary.  
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service April 27, 
2023.  You asked the Plan to pay for procedure code 88342. You say that these services were necessary and were 
reported appropriately. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88342 is 4. The MAI value for this code is 3. You billed 6 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88342 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88342 billed for date of service April 27, 2023.