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

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99497 for date of service June 
26, 2022. 
 You asked the Plan to pay for procedure codes 99223 and 99497. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as 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 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 find that CPT code 99223 is not supported in the medical record. Specifically, the submitted medical 
records do not include an evaluation and management note for the billed date of service. In this case, we have 
confirmed that code 99497 is a column II code to column I code 99223. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on this information, we decided that Medicare rules for coverage 
of procedure codes 99223 and 99497 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 99223 and 99497 for date of service June 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
from September 17, 2022, to October 7, 2022. 
 
You asked the Plan to pay for the heating pad. You say that this item was medically necessary. 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 a water circulating heat pad with pump will be 
denied as not reasonable and necessary.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the heating pad have not been met. Therefore, we decided that the Plan does not have to pay for the 
water circulating heat pad with pump (E0217) provided from September 17, 2022, to October 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport and ground mileage provided on November 2,  2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport and ground 
mileage.. You say that the submitted medical records support the ambulance transport was medically necessary.  
The Plan denied your request. The Plan says this claim does not meet these requirements for the ambulance 
transport.  
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport and ground mileage.  Our reviewer says that the ambulance services were not 
medically necessary.  Our physician reviewer found the transportation via ambulance from the hospital to the enrollee's residence 
upon discharge was not medically necessary. The enrollee did not require the expertise of trained personnel or 
the equipment available only on an ambulance in order to effectuate a safe transport.  Transportation could 
have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the 
enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport and ground 
mileage have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, 
basic life support, non-emergency transport and ground mileage provided on November 2,  2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for  the methylprednisolone (J1040) injection (20610) provided on 
September 7, 2022. 
 
You asked the Plan to pay for  the outpatient services. You say that the medical records indicate the medical 
necessity of the performed services. The Plan denied your request. The Plan says that services provided by a 
nurse practitioner are not covered unless preauthorized. 
 
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. Specifically, the file does not support the Plan's denial. There is no 
documentation provided that indicates the services were rendered by a nurse practitioner (NP) and are not 
payable. Therefore, we decided that the Plan has to pay for  the methylprednisolone (J1040) injection (20610) 
provided on September 7, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve Intracept procedure. You say that this procedure improves the quality of life 
of people suffering with vertebrogenic low back pain. The Plan denied your request. The Plan says the 
requested procedure 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 Intracept procedure. Our reviewer says 
that the requested Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the provided documentation show that the enrollee has leg pain symptoms which are 
a relative contraindication to the requested procedure. Therefore, the reviewer found that the requested Intracept procedure is not medically reasonable or 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 Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) (64628, 
64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97750 billed for date of service November 2, 
2022. 
 
You asked the Plan to pay for procedure code 97750. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 97750 is bundled into payment for code 97530. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also state that providers may bill services with a -59 modifier if the service billed with the modifier 
indicates a distinct procedural service.  Providers must report services with the appropriate CPT code. In this 
case, we have confirmed that code 97750 is a column II code to column I code 97530. While code 97750 was 
billed with modifier -59, the medical records provided do not show that the service billed with the -59 modifier 
is a distinct procedural service. Based on this information, we decided that Medicare rules for coverage of 
services billed with a -59 modifier have not been met. 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 97750 billed 
for date of service November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99218-25 billed for date of service November 28, 2022. 
 
You asked the Plan to pay for code 99218-25. You say that this code was billed with a 25 modifier, so separate 
payment is allowed. The Plan denied your request. The Plan says the use of the 25 modifier to allow for 
separate payment of code 99218 for date of service November 28, 2022, is not supported in the medical record. 
The documentation submitted does not support a significant, separately identifiable evaluation and 
management service to support the use of the -25 modifier.  
 
The Plan follows Medicare rules. Medicare rules say that modifier 25 is used for significant, separately 
identifiable evaluation and management service by the same physician on the same day of the procedure or 
other service. 
 
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 code 99218-25. Our reviewer says that the 
use of the 25 modifier to allow for separate payment of code 99218 is not supported by the medical records. Our physician reviewer found the evaluation and management service provided is related to the procedure 
provided on the same date of service, which would be included in the global period.  The evaluation and 
management record documents "Hospital course; No notes on file; Lesion of bladder - (present on admission); 
Assessment & Plan; Proceed with OR as planned below".  A cystoourethroscopy was performed on same date 
of service which has a global period. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99218-25 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99218-25 billed for date of service November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF (81455) provided December 31, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this letter and the attached documents 
support the medical necessity of the tests requested  The Plan denied your request. The Plan says Tempus xF 
has not had FDA approval or clearance as a companion in vitro diagnostic or an FDA-approved or -cleared 
indication for use in this patient's cancer.  
 
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 Tempus xF 
test at issue in this case meets all Medicare NCD criteria for medically reasonable and necessary for the 
enrollee. The provided records in this case do not document that the Tempus xF test is Food & Drug 
Administration (FDA) approved or has clearance as a companion in vitro diagnostic and the test has an FDA-
approved or cleared indication for use in this enrollee's cancer as required by the National Coverage 
Determination - Next Generation Sequencing (NGS) (90.2). 
 
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 the Tempus xF (81455) provided December 31, 2022.
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 
25, 2022, to December 2, 2022. 
 
You asked the Plan to pay for procedure code S9501. You say that the code denied in error. 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 25, 2022, to December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 billed for date of service September 10, 2022. 
 
You asked the Plan to pay for code 99223. You did not provide a specific argument with your appeal request. 
The Plan denied your request. The Plan says code 99223 is not supported by the medical record. The medical 
records don't support a comprehensive exam.  
 
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 by the medical record. Our reviewer found the patient is an 85-year-old male who was treated in the 
hospital. An infectious disease consultation took place. The provided note described the patient's presentation 
from many months prior with the documenting physician but currently with fever, using PermCath for dialysis 
and received antibiotics while undergoing sepsis workup. The physical examination was brief and noted "no 
cellulitis changes." The plan included following up on blood cultures and continuing antibiotics. The patient 
appeared stable, otherwise. However, the provided documentation did not sufficiently support the code, 99223. 
The records did not support a comprehensive history or examination, nor did they support medical decision-
making of high complexity as required 
 
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 September 10, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the arthrocentesis (20611). 
 
You asked the Plan to pay for the arthrocentesis. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the arthrocentesis. Our reviewer says that the 
requested service is considered medically reasonable and necessary in this case.  Our physician reviewer found 
the enrollee tolerated the initial injections well and is ready to proceed with the third. The exam revealed no 
effusion, no signs of infection, and no acute change from the previous evaluation. The use of ultrasound is 
documented. 
 
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 arthrocentesis have been met. Therefore, we decided that the Plan has to pay 
for the arthrocentesis (20611).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on October 31, 
2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says records do not support the billed service. 
 
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 99285 is an Emergency Department visit for the 
evaluation and management of a patient requiring a comprehensive history, a comprehensive examination 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 the emergency room services. Our reviewer says that the 
records provided do not support the code billed. Our reviewer found  the medical records submitted did not 
support a medical decision of high complexity. 
 
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 emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99285) provided on October 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 4, 2022, to 
February 14, 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. You say that 
diagnoses of I50.23 (acute on chronic systolic (congestive) heart failure) and J18.9 (pneumonia, unspecified 
organism) are supported in the medical record and were billed appropriately. The Plan denied your request. The 
Plan says the billed diagnoses of I50.23 (acute on chronic systolic (congestive) heart failure) and J18.9 
(pneumonia, unspecified organism) 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 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 diagnoses of I50.23 (acute on chronic systolic 
(congestive) heart failure) and J18.9 (pneumonia, 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 billed diagnoses of I50.23 (acute on chronic systolic (congestive) heart failure) and J18.9 (pneumonia, 
unspecified organism) are not supported in the medical record. Our physician reviewer found there are no 
criteria present to code for pneumonia. The patient's heart failure is chronic. She does not have an acute 
exacerbation. Her ejection fraction and brain natriuretic peptide do not define acuity. She very easily could be 
non-compliant with meds or diet and have chronic heart failure. Her absence of symptoms indicate chronicity 
rather than an acute condition. Her heart rate and blood pressure were normal indicating no acute 
decompensation.  
 
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 February 4, 2022, to February 14, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on 12/11/2021, through 
12/14/2021, 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 of 
A41.9, Sepsis. Our physician reviewer found the documentation provides a SOFA score of 1, which is 
insufficient to support the sepsis diagnosis as it does not meet Sepsis 3 criteria. The member did not have 
sufficient evidence to suggest the infection caused a life-threatening dysregulated response. Therefore, 
diagnosis code A41.9 remains unsupported.  
 
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 12/11/2021, through 12/14/2021, and billed with diagnosis code 
A41.9.