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

 
We decided that the Plan does not have to pay for code 99222 billed for date of service July 14, 2022. 
 
You asked the Plan to pay for code 99222. You say that this service was medically necessary. The Plan denied 
your request. The Plan says code 99222 is not supported by the medical record. The records don't support a 
comprehensive history and comprehensive examination. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) 
and the patients and/or familys needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patients 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 code 99222. Our reviewer says that code 99222 is not 
supported by the medical record. Our reviewer found the enrollee is a 50-year-old female who was treated in 
the Emergency Department (ED). The documentation provided from this date described the enrollee with 
chronic worsening abdominal pain. Ultrasound showed cholelithiasis. The enrollee was given Norco. 
Computed tomography was ordered after finding firm ventral hernia on examination. The history and exam 
were each an expanded focus, detailed but not comprehensive and the encounter note did not detail the 
encounter lasting 50+ minutes as required to justify code 99222.  
 
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 99222 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99222 billed for date of service July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96040 billed for date of service July 6, 2023. 
 
  You asked the Plan to pay for procedure code 96040. You say that Medicare allows multiple services if the 
providers have different specialties. You say that the medical records should be reviewed, and the claim 
processed for payment. The Plan denied your request. The Plan says procedure code 96040 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 96040 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 96040 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 96040 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 96040 billed for date of service July 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00170 billed for date of service May 3, 2023. 
 
You asked the Plan to pay for the billed services. You say that the coding is valid and payable. The Plan denied 
your request. The Plan says the service is not covered unless the primary service is covered. 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 00170 is anesthesia for intraoral procedures, including 
biopsy; not otherwise specified. We find that CPT code 00170 is not supported. Anesthesia services are 
covered when they are rendered during covered procedures. The documentation does show that the enrollee 
received extractions. However, the documentation does not show whether the extractions were approved or 
covered in this case. 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 00170 
billed for date of service May 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring brand non-pneumatic compression 
device (k1024, K1033). 
 
You asked the Plan to pre-approve a Koya Dayspring brand non-pneumatic compression device. You say that 
the item is medically necessary. The Plan denied your request. The Plan says this is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Koya Dayspring brand non-pneumatic 
compression device. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this specific device does not have sufficient current high-
quality evidence to show long-term benefit or superior efficacy over standard compression devices in the 
treatment of lower extremity edema.  
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 Koya Dayspring brand non-pneumatic compression device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Koya Dayspring brand non-pneumatic 
compression device (k1024, K1033).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 93247 rendered on March 18, 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 Current Procedural Terminology (CPT) 93247 remains 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 93247 is "External electrocardiographic recording for more than 7 days up to 15 days by continuous 
rhythm recording and storage; scanning analysis with report." 
 
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 supported by the medical records. Our reviewer found that the procedure code represents halter 
monitor for more than 7 days up to 15 days by continuous rhythm recording and storage; scanning analysis 
with report. The medical records include a report for a halter monitor for dates of service, March 1, 2023 to 
March 15, 2023 with documented time "13 23h 9min", which includes a scanning analysis with report.  In this 
case, documentation supports the procedure and should be covered. 
 
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 code 93247 rendered on March 18, 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: 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 enrollee will deteriorate if they do not receive 
proper inpatient rehab. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval.  
 
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 
was admitted for lumbar spine surgery. Medical problems are stable. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 13121 rendered on February 16, 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 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 code 13121 is "Repair, complex, scalp, arms, and/or legs; 2.6 
cm to 7.5 cm." 
 
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 a procedure report for a complex 
repair was not found in the documentation, and therefore 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 procedure code 13121 rendered on February 16, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Lucentis. 
 You asked the Plan to pre-approve Lucentis. You say that the enrollee is having an inadequate response to 
Avastin. The Plan denied your request. The Plan says the Plan requires a trial of Byoovis before it will approve 
Lucentis. 
 
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 Lucentis. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Lucentis. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of Byoovis. The record does not show that this drug 
will likely be less effective and/or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Lucentis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 25210-FA rendered on May 31, 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 the denial of this code is appropriate, as the modifier use was inappropriate. 
 
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 25210 is "Carpectomy; 1 bone." 
 
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 in this case. Our reviewer found that the provided records document an excision of 
the left trapezium. The surgery code (CPT 25210) was reported with modifier FA. This modifier is used to 
indicate a procedure was done on the left thumb. The trapezium is classified by the American Medical Association Current Procedural Terminology (CPT) codebook as part of the wrist and not part of the thumb. 
Modifier FA is not appropriate based on these coding guidelines. Modifier FA is not appropriate based on these 
coding guidelines. 
 
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 procedure code 25210-FA rendered on May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0367 and D0365), gingival 
irrigation (D4921), oral hygiene instructions (D1330), and intraoral imaging (D0230) provided on May 16, 
2023, to May 31, 2023.  
 
You asked the Plan to pay for the dental services. You say that this was a billing issue on the Plan's side. The 
Plan denied your request. The Plan says these services have been processed correctly. 
 
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, certain limitations apply. The record 
shows your benefit for D0230 was exhausted on date of service May 16, 2023. The remaining dental services 
are not covered benefits. The dental services not mentioned in this letter have been reprocessed and paid. Therefore, we decided that the Plan does not have to pay for a cone beam CT capture (D0367 and D0365), 
gingival irrigation (D4921), oral hygiene instructions (D1330), and intraoral imaging (D0230) provided on 
May 16, 2023, to May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care. 
 
You asked the Plan to pre-approve chiropractic care. You say that chiropractic care helps your pain and you do 
not want pain pills. The Plan denied your request. The Plan says chiropractic care is not covered for your 
condition. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve chiropractic care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on April 6, 2023, billed with 
procedure codes 93040-59 and 95924. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was 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 93040-59 and 95924 is rhythm electrocardiogram 
(ECG), 1-3 leads; with interpretation and report, and testing of autonomic nervous system function; combined 
parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt. 
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the record does not support 93040 as 
a separately identifiable procedure. The record states that the electrocardiogram (ECG) was part of the 
procedure reported with 95923 and should not be reported separately with modifier 59. CPT code 95924 is not 
supported. The record does not contain evidence that autonomic nervous system testing was performed with at 
least 5 minutes of passive tilt. 
 
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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on April 6, 2023, billed with procedure codes 
93040-59 and 95924.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99213-
24) rendered on July 20, 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 this is included in the minor surgery procedure. 
 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 99213 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 low level of medical decision making. When using time for code selection, 20-29 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 services at issue in 
this case were not supported by the medical records. Our reviewer found that the records document that the 
enrollee was seen on July 20, 2023 for a follow-up on a right knee surgery from April 21, 2023. During the 
visit for the knee the patient also reported hip pain and the patients right trochanteric bursa was injected with 
lidocaine, Marcaine and Depo-Medrol. The visit was billed as 99213-24 along with 20610 and 31030.  The 
provided records in this case do not support that the appropriate modifier was used for the apparently unrelated 
procedure provided during the office visit for the knee.  
 
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 99213-24) rendered on July 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a practitioner visit provided on February 3, 2023. 
 
You asked the Plan to pay for practitioner visit. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says this service was billed with modifier -HE with is classified as not payable by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that all line items on all types of bills using modifier -
HE will be denied.  
 
We looked at the file and Medicare rules. This service was billed with modifier -HE which is not payable and 
will be automatically denied. Based on this information, we decided that Medicare rules for coverage of 
practitioner visit have not been met. Therefore, we decided that the Plan does not have to pay for a practitioner 
visit provided on February 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the traction equipment (E0849), provided on June 8, 2023. 
 
You asked the Plan to pay for the traction equipment. You say that the item should be covered. The Plan denied 
your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. There is no indication this item was needed or ordered in the medical records submitted. The diagnosis listed on the prescription is not listed in the medical records. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the traction equipment (E0849), provided on June 
8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a continuous positive airway pressure (CPAP) 
device (E0601) and related accessories. 
 
You asked the Plan to pre-approve a CPAP device and related accessories. You say that the requested items are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage of CPAP 
have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that continued coverage of a PAP device requires that 
the treating practitioner must conduct a clinical re-evaluation and document that the enrollee is benefiting from 
PAP therapy.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device and related accessories have not been met. Specifically, documentation of the 
enrollee's adherence to PAP therapy is not evident in the case record. The benefit of PAP therapy has not been 
demonstrated in this case. Therefore, we decided that the Plan does not have to pre-approve use of a continuous 
positive airway pressure (CPAP) device (E0601) and related accessories.