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

 
We decided that the Plan does not have to pay for code 99233 billed for dates of service March 21, 2023, to 
March 23, 2023. 
 
You asked the Plan to pay for code 99233. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 99233 is not supported by the medical record. The records don't 
support a high level of decision making or the total time required. 
 
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 inpatient or observation 
care, per day, for the evaluation and management of a patient, which requires a medically appropriate history 
and/or examination and high level of medical decision making. 
 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 99233. Our reviewer says that the medical records do 
not support the billing of code 99233. Our reviewer found the patient is an 82-year-old man with a history of 
mesothelioma was admitted to the hospital for shortness of breath. He was found to have a large pleural 
effusion requiring thoracentesis and was treated for pneumothorax. In this case, the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level. 
 
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 99233 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99233 billed for dates of service March 21, 2023, to March 23, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care services provided from October 27, 2021, 
to November 22, 2021. 
 
You asked the Plan to pay for home health care. You say that the documentation supporting these services has 
been submitted. The Plan denied your request. The Plan says an OASIS (Outcome and Assessment Information 
Set) assessment was not received timely. 
 
The Plan follows Medicare rules. The rules say that an OASIS (Outcome and Assessment Information Set) 
assessment is a condition of payment for Home Health periods of care. OASIS reporting regulations require the 
OASIS to be transmitted within 30 days of completing the assessment of the beneficiary. 
 
We looked at the file and Medicare rules. The submitted records do not include documentation showing that an 
OASIS assessment was completed and transmitted within 30 days of completing the assessment of the beneficiary. Therefore, we decided that the Plan does not have to pay for home health care services provided 
from October 27, 2021, to November 22, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
April 10, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you were not 
aware a cost share would be applied. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for Emergency Care. 
 
You have been asked to pay a $90 copayment for an emergency room (ER) visit. This item/service falls within 
the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
(ER) visit provided on April 10, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve the FreeStyle Libre 3 sensor. The Plan denied your request. The Plan says 
that you do not meet the criteria for the CGM.  
 
The Plan must follow 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 the FreeStyle Libre 3 sensor. Our 
reviewer says that the FreeStyle Libre 3 sensor is medically necessary.  
Our physician reviewer found you are using insulin and hence meets coverage criteria for CGM use. You are 
an ideal candidate for this as you are new to insulin and likely will be having lows and highs and could learn 
much about diet/food impact your blood glucose sugar levels. 
 
We looked at this physician's review, the file, and Medicare rules. The Freestyle Libre 3 is now a covered 
device, as it has been assigned the covered code of E2103 as of June 15, 2023. Based on this information, we 
decided that Medicare rules for coverage of the FreeStyle Libre 3 sensor have been met. Therefore, we decided 
that the Plan has to pre-approve a FreeStyle Libre 3 sensor.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the records provided support medical necessity. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 pre-approve the PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found National Comprehensive Cancer Network 
(NCCN) guidelines state that imaging (with either CT or PET scan) is recommended every 312 months for 2 
years, then every 612 months for another 3 years to screen for recurrence or metastatic disease. Routine 
imaging to screen for asymptomatic recurrence or metastatic disease is not recommended after 35 years, 
depending on risk of relapse. The enrollee has been followed for 5 years with imaging surveillance. There is no 
note to suggest that there are symptoms to warrant imaging. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips for medical 
appointments that include your chemotherapy treatment which is every 21 days. The Plan denied your request. 
The Plan says the evidence shows you have used thirty-four (34) one-way trips of the thirty-four (34) one-way 
trips covered by your plan for the year 2023. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 34 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips for your medical appointments. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration - resorbable barrier, per site 
(D4266), and bone graft at time of implant placement (D6104) provided on March 1, 2023. 
 
You asked the Plan to pay for the guided tissue regeneration and bone graft at time of implant placement. The 
Plan denied your request. The Plan says these services are not covered under your benefit contract. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for guided 
tissue regeneration - resorbable barrier, per site (D4266), and bone graft at time of implant placement (D6104) 
provided on March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-comprehensive series of radiographic images 
(D0210) provided on May 17, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
has already been exhausted. 
 
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 the service provided was exhausted on date of service December 29, 2022.   
 
 
Specifically, the Plans contract states that an intraoral-comprehensive series of radiographic images and 
associated services are covered once every three years. You previously received a panoramic radiographic 
image on December 29, 2022 which is an associated service, less than three years prior, that was paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for the service provided in this case. Therefore, we 
decided that the Plan does not have to pay for the intraoral-comprehensive series of radiographic images 
(D0210) provided on May 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with the following codes: 81225, 81226, 
81227, 81231, 81232, 81240, 81241, 81291, 81306, and 81328. 
 
You asked the Plan to pay for the lab services. You say that this testing was medically necessary and ordered 
by the patient's doctor. The Plan denied your request. The Plan says you should have billed these lab services as 
a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single code shall be reported. 
 
 In this case, instead of billing a single code with a single unit of service, you billed a list of codes for one 
multigene panel.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services billed with the following codes: 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 
and 81328.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel (87481, 87511, 87556, 87640, 87653 
and 87798) provided on March 15, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the laboratory panel (87481, 87511, 87556, 87640, 87653 and 87798) provided on March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365-59 and 96366-59 billed for date of 
service May 8, 2023. 
 
You asked the Plan to pay for procedure codes 96365-59 and 96366-59. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these codes are 
not supported in the medical record; the services provided would be better reported with different codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT/HCPCS code. 
 
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 96365-59 and 96366-59. Our reviewer says 
that these codes are not supported in the medical record. Our reviewer found the procedure report describes 
intravenous insulin treatment provided for an outpatient. In this case, there is a more specific HCPCS code that 
should be reported for the documented services. 
 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 96365-59 and 96366-59 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 96365-59 and 96366-59 billed for date of 
service May 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on February 17, 
2023. 
 
You asked the Plan to pay for ConfirmMDx testing. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not provided for a covered indication. 
 
The Plan follows Medicare rules. Medicare rules say that applications of molecular biomarkers to risk-stratify 
patients at increased risk for prostate cancer are covered either before an initial biopsy or to obviate the need for a repeat biopsy. 
 
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 ConfirmMDx testing. Our reviewer says that 
the requirements for coverage of this testing were not met. Our physician reviewer found the records show that 
the enrollee has had a previous biopsy, but the enrollee was not undergoing this molecular biomarker test post-
biopsy to obviate the need for a repeat biopsy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ConfirmMDx testing have not been met. Therefore, we decided that the Plan 
does not have to pay for ConfirmMDx testing (81551) provided on February 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 64612-50 billed for date of service May 9, 2023. 
 
You asked the Plan to pay for code 64612-50. You say that the medical records support payment of this code. 
The Plan denied your request. The Plan says code 64612-50 is not supported by the medical record. There is a 
more appropriate code (64615) that should have been 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 64612-50 is Chemodenervation of muscle(s); muscle(s) 
innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm). 
 
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 64612-50. Our reviewer says that code 64612-50 is not 
supported by the medical record. The procedure report describes a bilateral procedure, however it was reported with a unilateral procedure code. This is not supported in the documentation, and in this case the procedure was 
incorrectly reported.  
 
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 64612-50 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 64612-50 billed for date of service May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on April 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided on April 6, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 17, 2023, to 
January 18, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the requirements for coverage were not met. 
 
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 records show that the enrollee presented with gangrenous cholecystitis. An inpatient 
admission with an expected stay of at least midnights was medically necessary and appropriate. 
 
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 January 17, 2023, to January 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93040, 93923, and 94761 billed for date of 
service June 28, 2022.  
 
You asked the Plan to pay for codes 93040, 93923, and 94761. You say that these services were billed 
correctly. The Plan denied your request. The Plan says these services are 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 93040 is rhythm electrocardiogram (ECG), 1-3 leads; 
with interpretation and report. The definition of 93923 is complete bilateral noninvasive physiologic studies of 
upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal 
posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with 
bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal 
posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more 
levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental 
transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative 
functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive 
hyperemia). The definition of 94761 is noninvasive ear or pulse oximetry for oxygen saturation; multiple 
determinations (eg, during exercise). 
 
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 93040, 93923, and 94761. Our reviewer says that these 
codes are not supported. Our reviewer found the submitted documentation does not support that procedure 
93040 was done distinctly from the approved procedure codes of 95921 and 95923. The documentation also 
does not fully indicate what studies were performed nor on what levels. The report does not fully explain and 
give the information needed to properly determine if code 93923 is correct. Code 94761 has a status indicator 
of "T" meaning it is bundled into other paid codes. 
 
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 93040, 93923, and 94761 have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 93040, 93923, and 94761 billed for date of service June 28, 
2022.