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

 
We decided that the Plan does not have to pay for the services (93458, 99152) provided on May 15, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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 93458 is "Catheter placement in coronary artery(s) for 
coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision 
and interpretation; with left heart catheterization including intraprocedural injection(s) for left 
ventriculography, when performed". The CPT Code Manual definition of code 99152 is "Moderate sedation 
services provided by the same physician or other qualified health care professional performing the diagnostic or 
therapeutic service that the sedation supports, requiring the presence of an independent trained observer to 
assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older". 
 
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 services. Our reviewer says that the use of codes 93458 
and 99152 is not supported by the records provided. Our reviewer found that for code 93458, the provider 
performs imaging supervision and interpretation for a coronary angiography with left heart catheterization and 
intraprocedural injections for left ventriculography. He performs these injections to assess any coronary artery 
disease or any stenosis within the artery. This procedure was not found in medical record, and therefore cannot 
be verified. For code 99152, the procedure report does not include sufficient documentation to verify per CPT 
code description "requiring the presence of an independent trained observer to assist in the monitoring of the 
patient's level of consciousness and physiological status". The procedure report documents "sedation 1st 15 
min". Therefore, this procedure cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (93458, 99152) provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce to copayment for the occupational therapy. We decided that the Plan 
does not have to reduce to copayments for the outpatient surgery, the office visits, and the duplex scan.  
 
You asked the Plan to reduce to copayments for the outpatient surgery, the occupational therapy, the office 
visits, and the duplex scan. You say that you should not owe this amount because the provider was in-network. 
The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce to copayment for the occupational therapy. 
 
The Plan contract says enrollees must pay a $40 copayment for occupational therapy at an in-network 
outpatient hospital. The file shows that you have been charged $104.99 for the occupational therapy received at 
the hospital. The Plan says you must pay a $104.99 copayment for the occupational therapy. Based on the plan 
contract, however, you cannot be asked to pay more than a $40 copayment for the occupational therapy. 
Therefore, we decided that the Plan has to reduce to copayment for the occupational therapy.  
 
We also decided that the Plan does not have to reduce to copayments for the outpatient surgery, the 
office visits, and the duplex scan. 
 
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 the outpatient surgery, and a $25 copayment for each of the office visits. You have been asked 
to pay a $10 copayment for the duplex scan, which is less than the standard copayment amount. Therefore, we 
decided that the Plan does not have to reduce to copayments for the outpatient surgery, the office visits, and the 
duplex scan. 
 
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: 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met.  
 
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. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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 pay for the services (99214) provided on June 29, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter". 
 
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 services. Our reviewer says that the use of code 99214 is not supported by the records provided. Our reviewer found that the history/exam are medically appropriate, but 
the decision-making does not reach a moderate level, nor is time of 30-39 minutes total time documented. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99214) provided on June 29, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 28, 
2023. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service and the attached reports support the level of service. You say that the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment 
for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 4, 2023, billed with 
evaluation and management (EM) code 99214-25. 
 
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 the level of care 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 99214-25 is office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter. 
 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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code Our reviewer found that the code, 99214-25 is not justified as 
the catheterization procedure codes include the history and physical portion in the global charge. There was no 
evidence that there was an unrelated medical consultation on that date separate from the procedure that would 
warrant this separate code. Therefore, the documentation does not sufficiently support the code, 99214-25.  
 
We looked at this physicians 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 March 4, 2023, billed with evaluation and 
management (EM) code 99214-25.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service July 1, 2023.   
You asked the Plan to pay for procedure code 99232. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the billed number of units are not 
supported by the records as both provided and medically necessary.  
 
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 99232 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE.  
 
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 99232. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found that the provided 
documentation does not reflect that the additional units of code 99232 were actually rendered or that they were 
medically necessary.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99232 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99232 billed for date of service July 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Sleep-number bed you purchased on April 3, 2023. 
 
You asked the Plan to pay for the Sleep-number bed. You say that you thought this would be covered, and you 
have faxed information to the Plan multiple times. The Plan denied your request. The Plan says this item is not 
covered, and you received it from a non-Medicare participating provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a Sleep-number bed you purchased on 
April 3, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on April 24, 2023, billed with 
procedure code 51785-26. 
 
You asked the Plan to pay for the testing 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 code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 51785-26 is needle electromyography studies (EMG) of 
anal or urethral sphincter, any technique. 
 
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 testing services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that there was no evidence of a separate test outside of the surgery for this date. Therefore, the provided documentation does not sufficiently support the 
procedure code 51785-26.  
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on April 24, 2023, billed with procedure code 51785-26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin barrier wipes or swabs (A5120) and adhesive 
remover wipes (A4456). 
 
You asked the Plan to pre-approve skin barrier wipes or swabs and adhesive remover wipes. You say that the 
items are medically necessary. The Plan denied your request. The Plan says these are not covered items. 
 
The Plan must follow Medicare rules. Medicare rules say that covered glucose monitoring supplies are batteries 
(A4233, A4234, A4235, A4236), alcohol or peroxide (A4244), alcohol wipes (A4245), Betadine or Phisohex 
solution (A4246), Betadine or iodine swabs or wipes (A4247), test strips or tablets (A4250, A4253), platforms 
(A4255), calibration solution (A4256), shield cartridges (A4257), lancets and lancet devices (A4258, A4259), 
disposable monitors (A9275), sensors (A9276), transmitters (A9277), receivers (A9278), bundled supply 
allowances (A4238, A4239), and miscellaneous durable medical equipment (A9999). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of skin barrier wipes or swabs and adhesive remover wipes have not been met. Skin barrier wipes and adhesive remover are not listed as covered glucose monitoring supplies. Therefore, we decided that the Plan 
does not have to pre-approve skin barrier wipes or swabs (A5120) and adhesive remover wipes (A4456).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services coded as 99232 and 
the advance care planning services coded as 99497 performed on February 22, 2023.  
 
You asked the Plan to pay for 99232 and 99497. You say that 99232 and 99497 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says 99232 and 
99497 are denied because they are not supported in the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99232 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 35 minutes must be met or exceeded. The CPT Code Manual definition of code 99497 is advance care planning including the explanation and discussion of advance directives such as standard 
forms (with completion of such forms, when performed), by the physician or other qualified health care 
professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. 
 
We find that CPT codes 99232 and 99497 are not supported in the medical record. Specifically, there is no 
documentation of an evaluation and management service or an advance care planning service for the billed date 
of February 22, 2023. Documentation included is for other dates of service. Based on this information, we 
decided that Medicare rules for coverage of 99232 and 99497 have not been met. Therefore, we decided that 
the Plan does not have to pay for the evaluation and management services coded as 99232 and the advance care 
planning services coded as 99497 performed on February 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from this care. 
The Plan denied your request. The Plan says the enrollee's condition does not meet the criteria for an LTACH 
admission, and needs can be met in the current setting. 
 
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 the enrollee does not require services at the LTACH that are not already available at 
the acute care hospital.  
 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A9279 billed for date of service May 8, 2023. 
 
You asked the Plan to pay for code A9279. You say that you disagree with the Plan's denial. 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 code A9279 has a Status Indicator of I on the Physician Fee Schedule. This means that code 
A9279 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of code A9279 have not been met. Therefore, we decided that the Plan does not have to pay for code 
A9279 billed for date of service May 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the disposable adult wipes (A4520). 
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says Medicare does not cover incontinence supplies because they are 
disposable, non-reusable hygiene items 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve the disposable adult wipes 
(A4520).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable imaging services (Q0092, R0070) provided on 
April 28, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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 Q0092 is "Set-up portable x-ray equipment". The CPT 
Code Manual definition of code R0070 is "Transportation of portable x-ray equipment and personnel to home 
or nursing home, per trip to facility or location, one patient seen". 
 
We find that CPT codes Q0092 and R0070 are not supported in the medical record. Specifically, the record 
does document that portable x-ray equipment set-up and transportation were performed on the date in question. 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 pay for the portable imaging services (Q0092, R0070) 
provided on April 28, 2023.