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

 
We decided that the Plan does not have to pay for code 99223 billed for date of service April 12, 2023. 
 
You asked the Plan to pay for code 99223. You say that the medical records support the billing of this code. 
The Plan denied your request. The Plan says code 99223 is not supported by the medical record. The medical 
records don't support a high level of medical decision making or total time required of the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is Initial hospital inpatient or observation care, per 
day, for the E/M of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision-making.  When using total time on the date of the encounter for code selection, 75 minutes 
must be met or exceeded. 
 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 99223. Our reviewer says that code 99223 is not 
supported by the medical record. Our reviewer found the procedure report documents "Total Time for 
Admission: 60 minutes", so the time does not support procedure code billed or a high level of medical decision 
making support. High level of medical decision making includes an extensive number of diagnosis or 
management options; an extensive amount and/or complexity of data to be reviewed, a high risk of 
complications and/or morbidity or mortality and high complexity level of complexity of medical decision 
making.  There is a more specific code that should be reported for service 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 code 99223 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99223 billed for date of service April 12, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoporosis. The documentation does not support that the enrollee has a history of 
osteoporosis-related fracture or the enrollee has failed or has a contraindication to zoledronic acid. The 
documentation does not support that zoledronic acid would likely be less effective and/or likely have adverse 
effects for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 12, 2023, to May 
5, 2023. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted on May 30, 
2023, and these services were medically necessary. 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 April 12, 2023. The NOA was not received by the Plan until May 30, 2023. 
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 home health services provided from 
April 12, 2023, to May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77003 billed for date of service May 12, 
2022. 
 
You asked the Plan to pay for procedure code 77003. You say that the claim was unjustly denied and needs to 
be reprocessed. The Plan denied your request. The Plan says payment for code 77003 is bundled into payment 
for code 64635. 
 
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 77003 
is a column II code to column I code 64635. 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 77003 billed for date of service May 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 20, 2023, to 
April 11, 2023. 
 You asked the Plan to pay for the home health services. You say that you have provided sufficient 
documentation to adjudicate this claim. The Plan denied your request. The Plan says the NOA was not 
received. As such, this final claim was correctly denied. The Plan says that although your appeal indicates that 
a NOA was submitted, none has been received. 
 
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 NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from March 20, 
2023, to April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the Transcutaneous electrical nerve stimulation (TENS) device supplies 
(A4595) 
 
You asked the Plan to pay for the TENS device supplies. You say that the item should be covered. The Plan 
denied your request. The Plan says that the item is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not give a clear reason as to why this appeal was denied or any 
evidence to support the denial. Therefore, we decided that the Plan has to pay for the Transcutaneous electrical 
nerve stimulation (TENS) device supplies (A4595)  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 24, 2022, billed 
with codes 81206, 81162, 81235, 81292, 81295, 81298, 81301, 81317, 81321, 81402, 81194, and 81309. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and Medicare rules. This NGS panel was not billed with a single code as required. The 
claim was billed with the laboratory POS code. The records do not support that the sample was taken in a 
laboratory setting. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on February 24, 2022, billed with codes 81206, 81162, 81235, 81292, 81295, 81298, 81301, 
81317, 81321, 81402, 81194, and 81309.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gauze pads (A6220), provided on March 17, 2023. 
 
You asked the Plan to pay for the gauze pads. You say that the item was medically necessary. The Plan denied 
your request. The Plan says this item is not covered when provided in an inpatient hospital. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the gauze pads were used in a SNF or hospital. Therefore, we decided that the Plan does not 
have to pay for the gauze pads (A6220), provided on March 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82607, 82746, 80061, 83036, 80053, 
83550, 82562, 85025, 83540, 84403, 86140, 81003 and 85652) provided on May 31, 2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and were 
reported appropriately. The Plan denied your request. The Plan says these services were billed with an 
inappropriate modifier. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, each of the codes at issue was billed with 
modifier 26; however, each of these codes also has a PC/TC indicator of 9, meaning that the concept of a 
professional/technical component does not apply. It is inappropriate to use the 26 modifier with these codes. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (82607, 82746, 80061, 
83036, 80053, 83550, 82562, 85025, 83540, 84403, 86140, 81003 and 85652) provided on May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided on April 7, 2023. 
 
You asked the Plan to pay for surgical assistant services. You say that the provider is eligible for payment. The 
Plan denied your request. The Plan says Certified First Assistants are not paid by Medicare. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. The file shows that Certified First Assistants are not paid by 
Medicare. Based on this information, we decided that Medicare rules for coverage of surgical assistant services 
have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services 
provided on April 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on March 18, 2022, 
to March 28, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code J15.6. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that diagnosis code J15.6 is not supported by the records provided. Our physician reviewer found 
that while the documentation supports a pneumonia, there is no clear evidence of a gram-negative bacteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services provided on March 18, 2022, to March 28, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99223) 
rendered from December 29, 2022, to December 30, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation guidelines require the history (past medical, family, and social) to be 
documented in the note. 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports a 
comprehensive exam, but not a comprehensive history or medical decision making of high complexity, or that 
70 minutes were spent. 
 
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 evaluation and management services (procedure code 99223) rendered from December 29, 
2022, to December 30, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer.  
You asked the Plan to pre-approve Injectafer. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Injectafer. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has iron deficiency anemia. The documentation does not support that the enrollee has tried 
Allergan or Venofer. The documentation does not support that Allergan or Venofer would likely be less 
effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria for 
the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
April 4, 2023, to April 13, 2023, and billed with codes 87798, 87481, 87500, 87640, 87653, 87641, and 81003. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on April 4, 2023, to April 13, 2023, and billed with codes 87798, 87481, 87500, 87640, 87653, 
87641, and 81003.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (code E0217) billed 
for dates of service January 19, 2023, to February 15, 2023. 
 
You asked the Plan to pay for code E0217. You say that this item was medically necessary based on medical 
literature. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that water circulating heat pads with pumps (code 
E0217) are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0217 have not been met. Therefore, we decided that the Plan does not have to pay for the 
water circulating heat pad with pump (code E0217) billed for dates of service January 19, 2023, to February 15, 
2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 99291 and 99292 rendered on May 1, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
the denied codes is: 
 
CPT 99291: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 
 
CPT 99292: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 
minutes (List separately in addition to code for primary service) 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were supported by the medical records. Our reviewer found that the documentation clearly states 
that the time spent in critical care management was 80 minutes. The documentation also supports that both 
codes were significant and separately identifiable critical care services from CPT 93503 and CPT 36620. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure codes 99291 and 99292 rendered on May 1, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on March 14, 2023, billed with 
procedure code 99152 
 
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 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 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 practitioner services provided . Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the record does not contain the time 
the provider spent at the patient's bedside performing moderate sedation, nor does it mention the presence of a 
trained, independent observer. These are requirements that must be met in order to report 99152. 
 
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 March 14, 2023, billed with procedure code 
99152