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

 
We decided that the Plan does not have to pay for the respiratory pathogen panel billed with code 87631 for 
December 13, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that respiratory pathogen panels with more than 5 
respiratory pathogens performed are considered not medically necessary. 
 
We looked at the file and Medicare rules. The file shows that more than five respiratory pathogens 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 the respiratory pathogen panel billed with code 
87631 for December 13, 2022.
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 June 21, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that medical records were provided. 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 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service December 3, 2022, and 
December 4, 2022. 
 
You asked the Plan to pay for code 99233. You say that the medical records support the level of service billed. 
The Plan denied your request. The Plan says procedure code 99233 billed for dates of service December 3, 
2022, and December 4, 2022, are not supported by the medical record. The record doesn't support a detailed 
interval history and medical decision making of high complexity. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of the 3 key components: A detailed interval 
history; A detailed examination; Medical decision making of high complexity. 
 
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 code 99233. Our reviewer says that code 99233 is not 
supported by the medical record. Our reviewer found the enrollee was a then, 78 year old male with a history of 
hypertension, hyperlipidemia, chronic obstructive pulmonary disease, coronary artery disease, and rheumatoid 
arthritis with recent open reduction and internal fixation complicated with wound infection. For the dates of 
service in question, code 99233 (2 Units) was not supported. This subsequent hospital care evaluation and 
management code requires two out of these three key components a detailed interval history a detailed 
examination and medical decision making of high complexity. In this case, the medical records submitted did 
not support a detailed interval history and medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for dates of service December 3, 2022, and December 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service August 14, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the code is supported. The Plan denied your 
request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 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. 
 
We find that CPT code 99223 is not supported in the medical record. The records show that the enrollee was 
treated for a leg fracture. The records do not show that decision making of high complexity 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 99223 billed for date of 
service August 14, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve polysomnography (95811). 
 
You asked the Plan to pre-approve polysomnography. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies and polysomnography refer to the 
continuous and simultaneous monitoring and recording of various physiological and pathophysiological 
parameters of sleep for 6 or more hours with physician review, interpretation and report. 
 
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 polysomnography. Our reviewer says 
that the services are medically necessary. Our physician reviewer found the review indicates that the enrollee is 
a 66-year-old female with a positive home sleep study: apnea-hypopnea index (AHI) 27.8. She requires a sleep 
study with continuous positive airway pressure (CPAP) titration. The review has determined that the enrollee 
meets the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polysomnography have been met. Therefore, we decided that the Plan has to 
pre-approve polysomnography (95811).  
 
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 64447-59 billed for date of service 
November 30, 2022. 
 
You asked the Plan to pay for the billed services. You say that the injection was completed separately. The Plan 
denied your request. The Plan says the code cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the records do not show that code 64447 is not ordinarily performed with the surgery 
performed. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 
modifier have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
64447-59 billed for date of service November 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87899 and 87900 billed for November 3, 
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 codes 87899 and 87900 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 87899 and 87900 is 87899 is infectious agent antigen 
detection by immunoassay with direct optical (ie, visual) observation; not otherwise specified. The definition of code 87900 is infectious agent drug susceptibility phenotype prediction using regularly updated genotypic 
bioinformatics. 
 
We find that CPT codes 87899 and 87900 are not supported in the medical record. Specifically, there is no 
documentation of infections agent antigen detection by immunoassay with direct optical observation to support 
code 87899. There is no documentation of infectious agent drug susceptibility phenotype prediction using 
regularly updated genotypic bioinformatics to support code 87900. 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 codes 87899 and 87900 billed for November 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit billed with code 99203 for December 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 global surgical package. 
 
The Plan must follow Medicare rules. The rules say that pre-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code 99203 was related to and billed on the same day as 
minor surgical procedure 13132. Payment for code 99203 is included in the global surgical payment for 13132. Therefore, we decided that the Plan does not have to pay for the office visit billed with code 99203 for 
December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 84443 and 85025 billed for date of service 
July 19, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the testing is not 
covered for the diagnoses listed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was provided for screening purposes. Medicare does not cover this testing for 
screening purposes. Therefore, we decided that the Plan does not have to pay for procedure codes 84443 and 
85025 billed for date of service July 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87502, 87503, 87634) provided on 
December 15, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says these services are not supported 
as separate and/or distinct from the other services provided. 
 
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 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 laboratory services. Our reviewer found for code 87634, 
the documentation submitted was reviewed and does not meet criteria. The laboratory report does not include 
documentation to support this procedure as a distinct procedural service from code 87631. To support modifier 
-59, the documentation must support a different session, different procedure or surgery, different site or organ 
system, separate incision/excision, separate lesion, or separate injury (or the area of injury in extensive injuries) 
not ordinarily encountered or performed on the same day by the same individual. For code 87502, the 
documentation submitted was reviewed and does not meet criteria. The laboratory report does not include 
documentation to support this procedure as a distinct procedural service from code 87631. To support modifier 
-59, the documentation must support a different session, different procedure or surgery, different site or organ 
system, separate incision/excision, separate lesion, or separate injury (or the area of injury in extensive injuries) 
not ordinarily encountered or performed on the same day by the same individual. For code 87503, the 
documentation submitted was reviewed and does not meet criteria. The laboratory report does not include 
documentation to support this procedure as a distinct procedural service from code 87631. To support modifier 
-59, the documentation must support a different session, different procedure or surgery, different site or organ 
system, separate incision/excision, separate lesion, or separate injury (or the area of injury in extensive injuries) 
not ordinarily encountered or performed on the same day by the same individual.  
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87502, 87503, 87634) provided on December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vascular study provided on January 26, 2023. 
 You asked the Plan to pay for a vascular study. You say that the enrollee was no longer active in hospice at the 
time of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 5, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for a vascular study 
provided on January 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
necessary because the enrollee is too complex for skilled nursing facility care. The Plan denied your request. 
The Plan says criteria for admission to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to an 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF visit provided from July 22, 2022, to 
August 15, 2022. 
 
You asked the Plan to waive the copayment for a SNF visit. You say that you feel you should not be 
responsible for the day of admission and day of discharge to the SNF. 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 $0 
copayment for days 1 to 20 and a $188 copayment for days 21 to 100 for SNF care.  
 
 
  You have been asked to pay a $752 copayment for a SNF visit ($188 per day x 4 days = $752). This 
item/service falls within the SNF care 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 waive the copayment for a 
SNF visit provided from July 22, 2022, to August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on November 
28, 2022. 
 
You asked the Plan to pay for principal care management services. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for principal care 
management services provided on November 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 15, 2022, to December 21, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this copayment is a 
financial hardship. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $225 copayment per day for days 1-5 of each inpatient hospital stay. The enrollees contract with 
the Plan also clearly says then enrollees do not have to pay a copayment after day five. 
 The enrollee has been asked to pay a $225 copayment per day for days 1-5 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. The enrollee has not been charged past day 
five or for the day of discharge. The enrollee has been asked to pay a total of $1,125 ($225 copayment per day 
x 5 days = $1,125). This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay 
provided from December 15, 2022, to December 21, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 18, 2023. 
 
You asked the Plan to pay for the ambulance services. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on January 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the SPECT and the emergency room 
services provided on December 28, 2022. 
 
You asked the Plan to waive the coinsurance for the SPECT and the emergency room services. You say that 
you were told you needed to go to the emergency room. 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 20% 
coinsurance for standard diagnostic procedures and tests. Your contract with the Plan also clearly says that you 
must pay 20% of the Medicare-approved amount up to $90 maximum for each emergency room visit. 
 
You have been asked to pay $107.28, which is 20% coinsurance of the allowed amount for the SPECT 
($536.40 allowed amount x 20% = $107.28). This item/service falls within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category. You have also been asked to pay $90, which is less than 
20% coinsurance of the allowed amount for emergency care. This item/service falls within the emergency care 
benefit category. You have been asked to pay a total of $197.28 ($107.28 coinsurance + $90 coinsurance = 
$197.28). 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 waive the coinsurance for the myocardial perfusion imaging and the 
emergency room services provided on December 28, 2022.