Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wearable defibrillator (K0606). 
 
You asked the Plan to pay for a wearable defibrillator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that a wearable defibrillator (K0606) is covered for 
beneficiaries if they meet one of the criteria listed 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 pay for a wearable defibrillator. Our reviewer says 
that the member does not need this item. Our physician reviewer found coverage of this item would not be 
considered medically necessary for this 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 a wearable defibrillator have not been met. Therefore, we decided that the Plan 
does not have to pay for a wearable defibrillator (K0606).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that the 
member does not need this item. Our physician reviewer found there is no indication the enrollee is insulin 
treated or has a history of problematic hyoglycemia. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 29, 2022, to 
November 6, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that documentation does not support level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case.  Our physician 
reviewer found the enrollee presented with a urinary tract infection, in the setting of end stage renal disease.  
Antibiotics and hemodialysis were required.  The documentation indicates a reasonable belief that, at the time 
of admission, two midnights of care would be required to further evaluate and treat 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from October 29, 2022, to November 6, 2022.  
 
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 hypertrophic cardiomyopathy panel (CPT 81439) provided 
December 12, 2022. 
 You asked the Plan to pay for the laboratory service. You say that  based on the above information and the 
physicians decision to order the test, you are requesting coverage at this time for the claim.  The Plan denied 
your request. The Plan says procedure code 81439 has met the associated deny relationship criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the test is described as a genetic based cardiovascular risk factor screening test in 
which multiple genes are assessed using genomic DNA extracted from patient sampling. It assesses the 
presence of pathogenic or likely pathogenic variants in genes known to be associated with increased cardiac 
risk. It is not a diagnostic test. There is no evidence to support its role in this enrollees clinical management. In 
summary, the requested testing is not considered reasonable or medically necessary. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for hypertrophic cardiomyopathy panel (CPT 81439) provided December 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for August 19, 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 1-12647062486 
 
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 these services. Our reviewer says that procedure code 99223 
is not supported. Our reviewer found the submitted records are for dates September 7, 2022, to September 9, 
2022 There are no records for the date of service at issue to support the billing of code 99223. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99223 billed for August 19, 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 October 18, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary.  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 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 billed services. Our reviewer found that the enrollee 
was being evaluated for gait issues and imaging that demonstrated a chronic subdural hematoma. He was 
admitted for evacuation. The review has determined the records supported that there was a comprehensive 
history and a comprehensive exam. However, there was not medical decision making of high complexity.  
 
We looked at this physicians review, the file, and Medicare rules. 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 October 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (0239U) provided on May 8, 2021. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this claim must be submitted to the enrollee's primary insurer before 
payment may be considered. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to bill the enrollee's primary insurer. As the secondary insurer, the Plan cannot be held responsible for 
the laboratory test until the primary insurer has denied the claim for these services.  Therefore, we decided that 
the Plan does not have to pay for the laboratory test (0239U) provided on May 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9501 billed for date of service November 
16, 2022, to November 17, 2022. 
 
You asked the Plan to pay for procedure code S9501. You say that this was the correct code to bill.  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 procedure code S9501 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9501 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9501 billed for date of service November 16, 2022, to November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99233 billed for date of service June 18, 2022, and code 
99232 billed for dates of service June 19, 2022, and June 20, 2022. 
 
You asked the Plan to pay for codes 99233 and 99232. You did not provide a specific argument with your 
appeal request. The Plan denied your request. The Plan says code 99232 billed for dates of service June 19, 
2022, and June 20, 2022, as well as code 99233 billed for date of service June 18, 2022, are not supported in 
the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 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. The definition of code 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
the 3 key components: An expanded problem focused interval history; An expanded problem focused 
examination; Medical decision making of moderate 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 codes 99233 and 99232. Our reviewer says that codes 99233 
and 99232 are not supported in the medical records provided. Our reviewer found the medical records supplied 
are for a different provider, and only from dates of service June 12, 2022, to June 17, 2022.  There are no 
records to support the codes and dates of service at issue in this appeal. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 99233 and 99232 have not been met. Therefore, we decided that the Plan 
does not have to pay for code 99233 billed for date of service June 18, 2022, and code 99232 billed for dates of 
service June 19, 2022, and June 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22845 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for procedure code 22845. You say that the services were provided by a surgical 
assistant at the request of the primary surgeon. You say that the operative notes support the billed services, and 
the claim should be reprocessed accordingly. The Plan denied your request. The Plan says payment for code 
22845 is bundled into payment for code 22853. 
 
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 22845 
is a column II code to column I code 22853. 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 22845 billed for date of service July 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 5, 2022, billed with 
codes 81407, 81479, 81238, 81405, 81406, 81286, 81403, 81408, and 81404. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and is 
supported in the medical record. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. 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 
October 5, 2022, billed with codes 81407, 81479, 81238, 81405, 81406, 81286, 81403, 81408, and 81404.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on March 13, 2022, 
to March 14, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says the documentation does not support that the criterion 
were met for inpatient hospitalization.  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case.  Our 
physician reviewer found this hospitalization does not qualify for inpatient payment under the two-midnight 
rule.  At the time of admission, it was not reasonable to expect that two midnights in the hospital would be 
required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on March 13, 2022, to March 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 24, 2022, 
through May 31, 2022, and billed with diagnosis code A41.9. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.9 is supported by the records. The Plan denied your request. The Plan says the documentation 
submitted does not support primary diagnosis of A41.9. 
 
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 primary diagnosis code A41.9-Sepsis unspecified 
organism. 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 the documentation does not support the primary diagnosis code 
A41.9, Sepsis.  Our physician reviewer found there was insufficient objective evidence of organ failure directly 
related to a dysregulated response to systemic infection to meet Sepsis 3 criteria. Therefore, the code, A41.9, is 
not supported in the documentation.   
 
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 inpatient hospital services provided on May 24, 2022, through May 31, 2022, and billed with diagnosis 
code A41.9.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mutation analysis precision panel (81455) provided July 26, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that please review the medical records for 
proving medical necessity. The Plan denied your request. The Plan says the available medical records do not 
support necessity of the service as defined by Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found based on the medical records provided there is no documentation that the mutation 
analysis precision panel at issue in this case meets all Medicare criteria for medically reasonable and necessary 
for the enrollee. The provided records in this case document the test in question has not been Food and Drug 
Administration cleared but that it is has been shown to be "clinically useful." The provided records include the 
test results but no other clinical information about this enrollees status to indicate medical necessity of the 
testing or how it would influence evaluation and treatment of this specific enrollees disease or other indication 
as to how it would be clinically useful for this 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 the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for mutation analysis precision panel (81455) provided July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service August 17, 2022. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary.  The Plan 
denied your request. The Plan says the testing is not covered as a screening service.  
 
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. 
 
We looked at the file and the rules. In this case, there are insufficient records to show that special stains were 
ordered due to signs and symptoms of a specific medical condition. Medicare does not cover this testing for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date 
of service August 17, 2022.