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

 
We decided that the Plan does not have to pay for procedure codes 99233 and 99239 billed for dates of service 
from August 27, 2021, to August 28, 2021. 
 
You asked the Plan to pay for procedure codes 99233 and 99239. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says the provided 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 99233 is: Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; 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 patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
The definition of code 99239 is: Hospital discharge day management; more than 30 minutes. 
 
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 procedure codes 99233 and 99239. Our reviewer says that 
procedure codes 99233 and 99239 do not meet criteria for payment. Our reviewer found that procedure code 
99233 requires 2 out of 3 of the following: a detailed interval history, a detailed examination and medical 
decision making of high complexity. The provided records do not support that there was a detailed interval 
history nor medical decision making of high complexity. The provided medical records do not support 
procedure code 99239 because the records do not document more than 30 minutes of hospital discharge day 
management. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 99233 and 99239 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 99233 and 99239 billed for dates of service from August 
27, 2021, to August 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service October 19, 2022. 
 
You asked the Plan to pay for code 99223. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 99223 is not supported in the medical record. The medical record 
does not support a comprehensive history. 
 
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 three key components: a comprehensive history, 
a comprehensive exam, and medical decision making of high complexity. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 99223. Our reviewer says that code 99223 is not supported in the medical record. Our reviewer found the enrollee was a then. 76-year-old male with a history of 
colon cancer, and non-Hodgkin Lymphoma who was admitted a left total hip replacement. There was no 
comprehensive history obtained on the day in question. 
 
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 October 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro orthotic device (L8702). 
 
You asked the Plan to pre-approve a MyoPro orthotic device. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
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 MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the MyoPro Orthosis is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of 
care for this enrollee's brachial plexus condition or in widespread use for this enrollee's condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this enrollee. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. 
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intrapulmonary percussive ventilator (IPV) (E0481). 
 
You asked the Plan to pre-approve an intrapulmonary percussive ventilator. You say that the enrollee has 
increasing symptoms due to ineffective airway clearance and is at increased risk for morbidity and mortality. 
The device is medically necessary. The Plan denied your request. The Plan says the requested device has not 
been demonstrated to be reasonable and necessary in the home setting. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare rules say the requested ventilator is not a covered benefit as 
it is not medically necessary in the home setting. Based on this information, we decided that Medicare rules for 
coverage of an intrapulmonary percussive ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intrapulmonary percussive ventilator (IPV) (E0481).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz (J7321, 20610). 
 
You asked the Plan to pre-approve Supartz. You say that this therapy is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Supartz. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that there is no documentation of an 
inadequate response to at least three months of conservative therapy. It was also found that the enrollee had a 
favorable response to the intra-articular steroid injection. The review has determined that the documentation 
does not support that the Supartz is medically reasonable or necessary for the enrollee. The documentation also 
does not support that the Supartz is safe and effective 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 Supartz have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Supartz (J7321, 20610).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group psychotherapy (procedure code 90853) rendered on 
September 15, 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 this service is not supported without the required 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 90853 is "Group psychotherapy (other than of a multiple-
family group)." 
 
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 medical records provided 
does not include sufficient documentation to validate that this service was rendered. The 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 group psychotherapy (procedure code 90853) rendered on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcatheter implant of wireless pulmonary artery 
pressure sensor (CardioMEMS). 
 
You asked the Plan to pre-approve CardioMEMS device. You say that the device is medically necessary. The 
Plan denied your request. The Plan says there is not enough evidence showing the requested device would 
improve the outcome for your condition. 
 
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 CardioMEMS device. Our reviewer 
says that the requested CardioMEMS device is not considered medically reasonable and necessary in this case. 
Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in the enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a transcatheter implant of wireless pulmonary artery pressure sensor 
(CardioMEMS).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on August 3, 2021. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was not billed 
with the appropriate DEX Z-code. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A57526. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the testing provided 
on August 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
from April 23, 2023, forward. 
 You asked the Plan to pre-approve SNF care. You say that you benefit from SNF care as your limited to needs 
for strengthening to continue to be able to return home. The Plan denied your request. The Plan says you have 
reached a level where rehabilitation is not predictable at this time and further progression cannot be expected in 
a reasonable time frame due to ongoing weight-bearing restrictions. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found despite continued skilled therapy, you are unable to make material gains. You remain 
non-ambulatory and unable to transfer without at least minimial assist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the continuation of skilled nursing facility (SNF) care from April 23, 2023, forward.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on November 17, 2021, billed 
with code 95822-26-XU. 
 
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 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 95822 is Electroencephalogram (EEG); recording in 
coma or sleep only. 
 
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 code. Our reviewer found the medical records attached did not 
clearly indicated if the Electroencephalogram was performed awake or asleep. 
 
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 November 17, 2021, billed with code 95822-
26-XU.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a smart lifter for a car (E1399). 
 
You asked the Plan to pre-approve a smart lifter for a car. You say that the requested lift is medically necessary 
because you need to lift your scooter into the car. The Plan denied your request. The Plan says the requested 
item does not serve a medical purpose and is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a smart lifter for a car (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service October 15, 
2022. 
 
You asked the Plan to pay for procedure code 99072. The Plan denied your request. The Plan says procedure 
code 99072 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 99072 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99072 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99072 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99072 billed for date of service October 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care 
from May 18, 2023, forward. 
 You asked the Plan to pre-approve SNF care. You say that you still need physical and occupational therapy to 
gain more weight and mobility. The Plan denied your request. The Plan says your request does not meet 
guidelines because you no longer require skilled services on a daily inpatient basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that you have had clinical and functional status 
change thus would be expected to require continued assessment by skilled nursing and skilled therapy. No 
recommendation for frequency of ongoing skilled nursing or skilled therapy required is provided thus there is 
no documentation to show that you require daily skilled services. No recent medication changes, blood 
pressure/glucose now stabilized. From a practical standpoint, there is no documentation to show that you 
require daily skilled services on an inpatient basis in a SNF; thus, not 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the continuation of skilled nursing facility (SNF) care from May 18, 2023, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an ILR is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you do not have a 
history of irregular heartbeat (atrial fibrillation) or any significant problems with heartbeat rate or rhythm 
(cardiac arrhythmia). The use of an ILR is not reasonable or medically necessary for your condition as this 
time. 
 
We looked at this physician'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 pre-approve an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 22, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says that the Plan did not 
receive the primary insurer's Explanation of Benefits (EOB). The Plan contacted the provider several times for 
the EOB; however, the EOB was not received to process as the secondary payer. 
 
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 not received 
the primary insurer's EOB. The Plan contacted the provider several times for the EOB; however, the EOB was 
not received to process as the secondary payer. As the secondary insurer, the Plan cannot be held responsible 
for the office visit until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing provided on November 26, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the coverage criteria are 
not met. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is covered for the indications 
established in the applicable NCD. 
 
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 testing. Our reviewer says that the 
requested testing was not medically reasonable and necessary. Our physician reviewer found that the enrollee is 
a 67-year-old female with small cell lung cancer. The requested Tempus xF testing is not medically reasonable 
and necessary according to the coverage criteria established in the NCD. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Tempus xF testing provided on November 26, 2022.