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

 
We decided that the Plan does not have to pay for procedure code J3490 provided on January 5, 2023. 
 
You asked the Plan to pay for procedure code J3490. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not supported in the records. 
 
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 J3490 is not supported in the medical record. Specifically, this code is included in the 
global surgery package of code 20610 that was billed for the same date. Based on this information, we decided 
that Medicare rules for coverage of procedure code J3490 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code J3490 provided on January 5, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 26, 2022, 
through November 28, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically 
necessary. The Plan denied your request. The Plan says that the enrollee could have received observation level 
of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 
emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from November 26, 2022, through November 28, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services (99285-25) provided on 
October 24, 2022. 
 
You asked the Plan to pay for the service. You say that the service is supported. The Plan denied your request. 
The Plan says the medical records submitted do not support a 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 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 the service. Our reviewer found the provided records in this 
case document a chief complaint, an extended history of present illness, a review of all additional body systems 
and a complete past, family and social history and a general multisystem examination. Records, however, do 
not document 2 out of 3 of an extensive number of diagnoses or management options, an extensive amount and 
complexity of data reviewed and high risk of complication. Therefore, the service is not supported by the 
records provided. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency department services (99285-25) provided on October 24, 2022.
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 every day is critical to recovery and the enrollee has 
not received proper rehabilitation needs, no one is at home that will be able to assist with care. The Plan denied 
your request. The Plan says the enrollee's records show that it is not reasonable to expect that you will be able 
to fully benefit from the intensity of services of an IRF. Services needed may be provided safely in a lower 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested radiofrequency ablation 
is medically necessary.  The Plan denied your request. The Plan says the enrollee does not meet criteria for 
radiofrequency ablation. 
 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 radiofrequency ablation. Our reviewer 
says that the enrollee does not meet criteria for radiofrequency ablation. Our physician reviewer found the 
records do not show that the physical exam correlated with facet joint 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
28, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99100 is 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 code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious-agent detection (87636) and additional resources 
(99072) billed for date of service November 30, 2022. 
 
You asked the Plan to pay for infectious-agent detection and additional resources. You say that the services at 
issue have been billed correctly. The Plan denied your request. The Plan says the claim for the molecular 
pathology testing at issue did not include the required unique identifier. The Plan also says that procedure code 
99072 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of infectious-agent 
detection have not been met. We also find that procedure code 99072 has a status indicator of B on the 
Physician Fee Schedule. This means that procedure code 99072 is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of additional resources (99072) have not been met. 
Therefore, we decided that the Plan does not have to pay for infectious-agent detection (87636) and additional 
resources (99072) billed for date of service November 30, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that there have been multiple studies showing the benefit of 
Botox for gastroparesis. The Plan denied your request. The Plan says Botox has not been proven effective in 
treating gastroparesis. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Botox. Our reviewer says that the 
requested use of Botox is not supported. Our physician reviewer found the record indicates that the enrollee has 
a diagnosis of gastroparesisis. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation.    
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure (64628 and 64629).  
 
You asked the Plan to pre-approve the services. You say that the intracept procedure is approved by the Food 
and Drug Administration (FDA). The Plan denied your request. The Plan says they consider intraosseous 
radiofrequency nerve ablation system to be experimental, investigational, or unproven.  
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found the records do not contain documentation of a magnetic resonance imaging (MRI) that shows 
modic endplate changes without facet degenerative joint disease (DJD) and foraminal stenosis. The cause of 
back pain is not clear.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intracept procedure (64628 and 64629).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA), neck; without 
contrast material(s) (70547) provided on February 8, 2023. 
 
You asked the Plan to pay for the MRA. You say that the service was billed correctly. The Plan denied your 
request. The Plan says a covered diagnosis has not been billed for magnetic resonance angiography (70547).  
 
The Plan must follow Medicare rules. The provider billed with diagnosis codes of R51.9, M21.371, E87.6, and 
Z99.2 therefore, these diagnosis codes do not fall under the coding and billing requirements set forth in the 
LCA A56747 as payable.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the MRA have not been met. Therefore, we decided that the Plan does not have to pay for the 
magnetic resonance angiography (MRA), neck; without contrast material(s) (70547) provided on February 8, 
2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the SelectMDx testing (81479) provided on August 16, 2022. 
 
You asked the Plan to pay for the testing. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says that the claim submitted is unclean due to a description is needed and 
the provider will need to claim with code description or documents showing that ZB5CC test is a code 
processed correctly per test.  
 
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 SelectMDx testing is a covered test, and the Plan has not given us any 
proven reason it cannot be paid. Therefore, we decided that the Plan has to pay for the SelectMDx testing 
(81479) provided on August 16, 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 the ambulance transport rendered on September 16, 2022. 
 
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 payment is included in the inpatient hospital payment. 
 
The Plan must follow Medicare rules. Medicare rules say that patient transportation from one hospital or SNF 
to another is included in the inpatient payment. 
 
We looked at the file and Medicare rules. The file shows that the services at issue are an ambulance transport 
from one hospital to another while the enrollee was inpatient. Payment for these services is included in the inpatient hospital payment. Therefore, we decided that the Plan does not have to pay for the ambulance 
transport rendered on September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service March 27, 
2022. 
 
You asked the Plan to pay for procedure code 99222. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the provided records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99222 is: Initial hospital 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 moderate 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 moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 99222. Our reviewer says that procedure 
code 99222 does not meet criteria for payment. Our reviewer found that the medical records provided do not 
support or show that the enrollee was admitted or an inpatient. Additional documentation would need to be 
submitted to show that the enrollee was admitted for observation or for inpatient status after surgery. 
 
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 99222 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99222 billed for date of service March 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 2, 2021, billed 
with codes 87798, 87653, 87651, 87641, 87640, 87551, 87500, 87481,  87471. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be considered a covered 
service as the diagnosis provided to order the test was not for preventative care and was in fact medically 
necessary to the treatment of such a diagnosis. The Plan denied your request. The Plan says panel testing 
should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 2, 2021, billed with codes 87798, 87653, 87651, 87641, 87640, 87551, 87500, 87481,  87471.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99232. We decided that the Plan does not have to pay 
for procedure codes 99222 and 99239.  
 
You asked the Plan to pay for inpatient care (99222, 99232, 99239) provided on October 20 to October 23, 
2022. You say that these services were medically necessary. The Plan says that the records do not support the 
codes billed. 
 
We decided that the Plan has to pay for procedure code 99232.  
 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 codes 99232. The reviewer says 
that the provided records do support the billed subsequent hospital care code, 99232. 
 
We also decided that the Plan does not have to pay for procedure codes 99222 and 99239. 
 
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 codes 99222 and 99239. Our 
reviewer says that these codes are not supported in the record. Code 99222 can be used for initial hospital 
inpatient care for the evaluation and management of a patient. The code can be used if the evaluation and 
management of a patient has a detailed or comprehensive history a detailed or comprehensive examination and 
medical decision making of moderate complexity. The records do not show these three requirements were 
met. Our physician reviewer found there is no documentation of a complex hospital discharge note to support 
code 99239. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99222 and 99239 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99222 and 99239. 
 
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 procedure code 99291 billed for date of service November 
14, 2022.  
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the denial. 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 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service November 14, 2022.