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

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on June 10, 2022. 
 
You asked the Plan to pay for the initial hospital care (99223). You say that the medical records have been 
submitted and the claim should be reconsidered for payment. The Plan denied your request. The Plan says the 
medical records submitted do not support a comprehensive history. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
  In this case, the CPT Code Manual definition of code 99223 is initial hospital care, 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, 70 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 the initial hospital care (99223). Our reviewer says that 
procedure code 99223 is not supported for this service date. Our reviewer found the provided records do not 
clearly show evidence of a comprehensive history or physical. In addition, there was no clear documentation 
describing 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 the initial hospital care (99223) have not been met. Therefore, we decided that 
the Plan does not have to pay for the initial hospital care (99223) provided on June 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve accu-chek softclix lancets (A4259). 
 
You asked the Plan to pre-approve diabetic lancets. You say that you disagree with the denial. The Plan denied 
your request. The Plan says only the preferred brand products listed in the EOC are covered. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for diabetic lancets. Therefore, we decided that the Plan does not have to pre-approve accu-chek softclix lancets 
(A4259).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for October 31, 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 procedure code G0483 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 G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records show that 14 
drug classes were tested. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0483 
billed for October 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from August 12, 2022, to 
September 10, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the denial. 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 rendered from August 12, 2022, to 
September 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from March 4, 2022, to 
April 2, 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 the NOA was not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 4, 2022. The NOA was not received by the Plan until November 9, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered from March 4, 2022, to April 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service August 31, 
2022. 
 You asked the Plan to pay for procedure code 11721. You say that this service was medically necessary and 
provided in good faith. The Plan denied your request. The Plan says payment for code 11721 is bundled into 
payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 11721 billed for date of service August 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services 
provided on September 6, 2022, billed with code 99222. 
 
You asked the Plan to pay for the evaluation. You say that procedure code 99222 was billed within the 
appropriate guidelines. The Plan denied your request. The Plan says the documents do not support this level of 
care. 
 
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 physician 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 evaluation. Our reviewer says that the documentation 
does not support procedure code 99222.  Our reviewer found that the history of present illness is appropriate, 
the review of systems is limited, the physical examination is not comprehensive.  As such, the billing of CPT 
99222 is not supported. 
 
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 evaluation have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient evaluation and management (EM) services provided on September 6, 2022, billed 
with code 99222.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service August 13, 
2022, to September 9, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the patient's physician referred them for this 
service, so the claim should be paid. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service August 13, 2022, to September 9, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient surgical services coded as 66984, J1097 and V2632 
provided July 1, 2021. 
 
You asked the Plan to pay for outpatient surgery. You say that please review for an appeal of duplicate denial 
of the replacement claim sent. The Plan denied your request. The Plan says that this claim is a duplicate of a 
previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The Plan has not provided proof that the claim was 
paid or partially paid, or if payment was made to another provider. Based on this information, we decided that 
Medicare rules for coverage of outpatient surgery have been met. Therefore, we decided that the Plan has to 
pay for the outpatient surgical services coded as 66984, J1097 and V2632 provided July 1, 2021.  
 
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 the emergency room (ER) services provided on November 4, 2022. 
 
You asked the Plan to pay for the ER services. You say that the services should be covered. The Plan denied 
your request. The Plan says that a freestanding ER is not eligible for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. Freestanding ERs can temporarily enroll as 
a Medicare certified hospital to provide hospital services to help address the urgent need to increase hospital 
capacity. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ER services have been met. Specifically, the provider was given temporary certification with 
Medicare. Therefore, we decided that the Plan has to pay for the emergency room (ER) services provided on 
November 4, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study, unattended, simultaneous recording; heart 
rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time 
(95800). 
 
You asked the Plan to pre-approve a sleep study. You say that the enrollee has obstructive sleep apnea and has 
tried bilevel positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP) which she is 
intolerant because she states that the mask suffocates her. The enrollee had her last sleep study from 2020 and 
needs an updated sleep study for placement of Inspire. The Plan denied your request. The Plan says the request 
cannot be approved because the requested sleep study for hypoglossal nerve stimulator (HGNS) pre-implant 
evaluation must be a diagnostic study. 
 
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 sleep study. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of obstructive sleep apnea with intolerance to CPAP. As 
summarized in Up to Date (Home sleep apnea testing for obstructive sleep apnea in adults, Author: Nancy 
Collop, MD), depending on the equipment used for the home sleep study, adequate information to clarify that 
implantation of a hypoglossal nerve stimulator would be appropriate may not be obtained from a home study as 
opposed to an in-lab study. Inability to distinguish between obstructive and central events is a limitation of 
some home study equipment and the sleep study must show that the enrollee has predominantly obstructive 
events (defined as central and mixed apneas less than 25% of the total AHI) in order to qualify for the 
hypoglossal nerve stimulator. The health plan has indicated that they would approve an in-lab sleep test if 
requested. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, 
respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time (95800).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on October 28, 2022. 
 
You asked the Plan to pay for the ambulance service. You say that the medical records provided support the 
need for the ambulance transport. The Plan denied your request. The Plan says this claim does not meet the 
requirements for non-emergency transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the ambulance service. Our reviewer says 
that the ambulance transport was not medically necessary Our physician reviewer found the transportation via 
ambulance from the enrollee's residence to the dialysis appointment was not medically necessary. The enrollee 
was not bedbound, as evidenced by the ability to sit in a dialysis chair/recliner.  The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance 
in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) without endangering the enrollee's condition. 
 
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 ambulance service have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport provided on 
October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 5, 2022, to 
February 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed. 
 The Plan follows Medicare rules. The rules say that the 30-day period payment rate is adjusted by a case-mix 
methodology based on information from home health claims, other Medicare claims, and data elements from 
the Outcome and Assessment Information Set (OASIS). 
 
We reviewed the file and the Medicare rules. We find that medical records did not contain the OASIS or any 
components of the initial comprehensive assessment per the requirements. 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 January 5, 2022, to February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with procedure code 99214 for date of 
service September 6, 2022. 
 
You asked the Plan to pay for the office visit. 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 99214 is not supported in the medical record. Specifically, this code was billed with 
diagnosis codes I65.01 (Occlusion and stenosis of right vertebral artery), I65.02 (Occlusion and stenosis of left 
vertebral artery), I65.21 (Occlusion and stenosis of right carotid artery), and I10-(Essential (primary) 
hypertension). It is inappropriate to bill both the right and left diagnosis codes for the same indication when a 
more specific (bilateral) code is available. This means the claim is not payable as billed. Based on this 
information, we decided that Medicare rules for coverage of the office visit have not been met.  Therefore, we decided that the Plan does not have to pay for the office visit billed with procedure code 99214 
for date of service September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC). 
 
You asked the Plan to pre-approve the PWC. You say that the enrollee requires the PWC for mobility. The Plan 
denied your request. The Plan says the records show the enrollee does not have a limitation in mobility related 
activities of daily living, or evidence that the enrollee does not have sufficient strength to use a manual 
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 PWC. Our reviewer says that the 
documentation does not support the medical necessity of the requested PWC. Our physician reviewer found the 
enrollee appears to be functionally non-ambulatory and likely unable to use a cane or walker for mobility. 
However, there is limited clinical history regarding the level of mobility and function, including her ability to 
transfer and perform activities of daily living. There is limited information regarding the enrollee's physical 
examination. She does appear to have weakness in the lower extremities, but there is limited documentation 
regarding the motor strength and range of motion in the upper extremities, which is important in determining if 
the enrollee can use a manual wheelchair for mobility. Lastly, no power mobility evaluation was performed to 
assess the enrollee's ability to safely use the requested group 2 power wheelchair and if her home is accessible 
for the requested power mobility device. 
 
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 PWC have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from March 23, 2022, to 
March 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must be 
submitted to the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the inpatient services provided from March 23, 2022, to March 27, 2022.