Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service July 11, 2023, billed with code 99153.  

You asked the Plan to pay for procedure code 99153. You say that the service should be paid. The Plan denied 
your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service July 11, 2023, billed with 
code 99153.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2951) provided on June 28, 2023. 
 
You asked the Plan to pay for D2951. You say that you needed all of this dental work. The Plan denied your 
request. The Plan says the denied dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core 
build-up (D2951) provided on June 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan and an injection to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve a PET scan and an injection. You say that the enrollee has cancer and 
requires a scan to check the progression of the disease. The Plan denied your request. The Plan says the 
enrollee must use an in-network provider for the requested services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a PET scan and an injection to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 
29, 2023, to June 28, 2023. 
 
You asked the Plan to pay for the SNF care. You say that the services should be covered under the Medicare 
Act. The Plan denied your request. The Plan says the enrollee did not meet the criteria for the SNF stay for 
those dates. 
 
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 pay for the 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 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 and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from May 29, 2023, to June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) provided on July 18, 2023. 
 
You asked the Plan to pay for D2950. You say that you cannot afford these charges. The Plan denied your 
request. The Plan says this claim has been reprocessed correctly. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a core 
build-up (D2950) provided on July 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on July 
18, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (E0675) provided on July 18, 2023.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 88346 and 88350. We decided that the Plan does not 
have to pay for procedure code 86153.  
 
You asked the Plan to pay for the lab testing billed for date of service June 27, 2023. You say that the testing 
was medically necessary. The Plan says that the coding is not supported. 
 
We decided that the Plan has to pay for procedure codes 88346 and 88350.  
 
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. 
 
We looked at the file and the rules. The Plan does not offer a rationale as to why these services were denied. It 
appears that the Plan did not review these codes on appeal. As the Plan forfeited its opportunity to provide a 
denial rationale for these services, we find that the denial of payment is not supported. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for procedure codes 88346 and 88350.  
 
We also decided that the Plan does not have to pay for procedure code 86153. 
 
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 86153 is cell enumeration using immunologic selection 
and identification in fluid specimen (e.g., circulating tumor cells in blood); physician interpretation and report, 
when required. We find that CPT code 86153 is not supported in the medical record. Specifically, the records 
provided did not include a physician interpretation and report. 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 86153 billed for date of service June 27, 2023. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999) provided on 
April 19, 2023, to May 4, 2023. 
 
You asked the Plan to pay for D9999. You say that you needed this dental work. The Plan denied your request. 
The Plan says the denied dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified adjunctive procedure (D9999) provided on April 19, 2023, to May 4, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 28470 billed for April 2, 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 procedure code 28470 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 28470 is closed treatment of metatarsal fracture; without 
manipulation, each. 
 
We find that CPT code 28470 is not supported in the medical record. Specifically, there is no documentation 
indicating that definitive fracture care was performed for the billed date of service. 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 28470 billed for April 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87798 billed for date of service 
July 18, 2023.  
 
You asked the Plan to pay for procedure codes 87481 and 87798. You say that you disagree with the Plan's 
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 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 87481 is 5 and the MUE for CPT code 87798 is 13. The MAI value for 
these codes is 3. You billed 6 units of code 87481 and 19 units of code 87798, 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 87481 and 87798 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 87481 and 87798 billed for date of service July 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the item is not medically necessary. Our physician reviewer found you do not require 
positioning of the body or special attachments. 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasonic guidance for placement of radiation therapy fields 
provided on April 11, 2023, to June 7, 2023. 
 
You asked the Plan to pay for ultrasonic guidance for placement of radiation therapy fields. You say that you 
are requesting reconsideration for the denied claim. The Plan denied your request. The Plan says the requested 
service does not meet the Medicare coverage criteria. 
 
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 pay for ultrasonic guidance for placement of 
radiation therapy fields. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the medical records provided and the 
National Comprehensive Cancer Network Guidelines, Version 2.2024, Basal Cell Skin Cancer, Principles of Radiation Therapy, there is no documentation that ultrasonic guidance for placement of radiation therapy fields 
meets all Medicare criteria for medically reasonable and necessary for the patient. Provided medical records 
and review of the current peer-reviewed medical literature do not document that use of the ultrasonic guidance 
has been shown in controlled studies in a Medicare-approved journal to result in sustained long term health 
benefits in patients with basal cell carcinoma of the skin. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasonic guidance for placement of radiation therapy fields have not been met. 
Therefore, we decided that the Plan does not have to pay for ultrasonic guidance for placement of radiation 
therapy fields provided on April 11, 2023, to June 7, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
February 7, 2023. 
 You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on February 7, 
2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the nuclear medicine study, the 
cardiovascular stress test, the regadenoson injection, and the technetium Tc-99m tetrofosmin injection provided 
by an in-network provider on July 18, 2023. 
 
You asked the Plan to reduce the cost sharing for the nuclear medicine study, the stress test, and the injections. 
You say that you think that the cost sharing should be lower. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for other in-network Medicare-covered radiological diagnostic services, including nuclear studies, 
performed in a physicians office or at a free-standing facility (such as a radiology center or medical clinic), a 
$20 copayment for in-network Medicare-covered non- radiological diagnostic services, including treadmill 
stress tests, a 20% coinsurance for each in-network Medicare-covered medical supply, and a 20% coinsurance 
for all other in-network Medicare-covered Part B drugs. 
 
You have been asked to pay a $150 copayment for the nuclear medicine study. You have been asked to pay a 
$20 copayment for the stress test. You have been asked to pay a $14 coinsurance for the technetium Tc-99m 
tetrofosmin injection ($70 allowed amount x .20 = $14). These items/services fall within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay a 
$48.92 coinsurance for the regadenoson injection ($244.60 allowed amount x .20 = $48.92). This item/service 
falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the 
cost sharing for the nuclear medicine study, the cardiovascular stress test, the regadenoson injection, and the 
technetium Tc-99m tetrofosmin injection provided by an in-network provider on July 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on November 22, 2022, to 
November 24, 2022, billed with procedure codes 99223 and 99233. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 99223 and 99233 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, and subsequent hospital care, per day, for the evaluation and management of a patient, which requires 
at least 2 of these 3 key components: A detailed interval history; A detailed examination; 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 patient is unstable or has developed a significant complication or a 
significant new problem. Typically, 35 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the documentation for November 22, 
2022, does not contain a comprehensive examination or medical decision making of high complexity. As such, 
the billing of CPT 99223 is not supported. The documentation for November 23, 2022, and November 24, 
2022, does not contain a detailed interval history or medical decision making of high complexity. As such, the 
billing of CPT 99233 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 the practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on November 22, 2022, to November 24, 2022, 
billed with procedure codes 99223 and 99233.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95957 billed for date of service June 9, 2023. 
 
You asked the Plan to pay for procedure code 95957. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says this code is not supported in the medical record. 
 
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 95957 is digital analysis of electroencephalogram (EEG) 
(e.g., for epileptic spike analysis). 
 
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 95957. Our reviewer says that this code is 
not supported in the medical record. Our reviewer found the procedure report does not include documentation 
of digital analysis of EEG. 
 
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 95957 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95957 billed for date of service June 9, 2023.