Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve cardiac catheterization (93458). 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 pre-approve cardiac catheterization. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found in this specific case, he may also benefit from direct measurement of left ventricular 
end-diastolic pressure (LVEDP), and pressure gradient across the aortic valve. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have been met. Therefore, we decided that the Plan has 
to pre-approve cardiac catheterization (93458).  
 
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 code 99285 billed for date of service January 13, 2023. 
 
You asked the Plan to pay for code 99285. You say that medical records were provided to support the billing. 
The Plan denied your request. The Plan says code 99285 was not supported by the medical record. As a result, 
this claim was down-coded to code 99284. 
 
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 Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 code 99285. Our reviewer says that code 99285 was not 
supported by the medical records. Our reviewer found the enrollee was a then 66 yo female who presented to 
the emergency room with left-sided abdominal pain. She was evaluated with a history and physical exam, 
laboratory studies and a computed tomography scan of the abdomen/pelvis. She was treated with IV fluids, IV 
Rocephin and IV Ketorolac. Her condition stabilized and improved, and she was discharged home with primary 
care follow-up. The review has determined that the documentation did not support procedure code 99285. 
Specifically, there was no medical decision making 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 code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service January 13, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 73110 billed for date of service January 11, 2023. 
 
You asked the Plan to pay for code 73110. You say that this service was medically necessary and provided in 
good faith. The Plan denied your request. The Plan says this code is not separately payable. 
 
The rules say that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. In 
this case, the code in dispute has a status indicator of QI, meaning that it is a STV-packaged service.  This 
disputed code was billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the code in dispute in this appeal is not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 73110 have not been met. Therefore, we decided that the Plan does not have to pay for code 
73110 billed for date of service January 11, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the vaccination services billed for date of service October 24, 2022. 
 
You asked the Plan to pay for the billed services. You say that the correct type of bill is 341. The Plan denied 
your request. The Plan says that a corrected claim is needed. 
 
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 claim provided does not show that the billing provider is a home health provider. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request.  Therefore, we decided that the Plan has to pay for the vaccination services billed for date of service 
October 24, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyvgart. 
 
You asked the Plan to pre-approve Vyvgart. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, 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 Vyvgart. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the accepted use of this drug requires 
acetylcholine receptor (AChR) antibodies being present for the enrollee, however, this was not shown in the 
provided records to help support the use of Vyvgart use. It's use in this case would be somewhat experimental 
due to lack of sufficient high-quality evidence to support its safety and effectiveness for this enrollee's specific 
condition. Therefore, Vyvgart will be considered not medically necessary at 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 Vyvgart have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vyvgart.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from December 1, 2022, to 
December 16, 2022.  
 You asked the Plan to pay for the home health services. You say that you have submitted the required NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 20, 2022. The NOA was not received by the Plan until February 
22, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from December 1, 2022, to December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service February 23, 
2023.  
 
You asked the Plan to pay for procedure code 99232. You say that the services provided by the physician are 
separately identifiable. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99232 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. Code 99232 is a per diem code. The record shows both codes were billed for the 
same provider and same date of service. You did not provide all the required evidence showing that the excess 
units were actually provided, were correctly coded, and were medically necessary. Based on this information, 
we decided that Medicare rules for coverage of procedure code 99232 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99232 billed for date of service February 23, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated mandibular advancement oral device 
(E0486) purchased on December 6, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the oral device. You say that you feel that the reimbursement should be 
processed as you need to be reimbursed and you already have a prescription for this. The Plan denied your 
request. The Plan says there is no evidence that you meet the criteria for coverage of the device. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. Also, there were no records provided for the enrollee has had an in-person clinical 
evaluation by the treating practitioner prior to sleep testing per LCD requirements. We found no exception that 
would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay 
for the custom fabricated mandibular advancement oral device (E0486) purchased on December 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from March 11, 2021, to 
March 12, 2021, 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 the 
billing of diagnosis code, N17.9, is supported. The Plan denied your request. The Plan says there is not 
sufficient documentation to clinically validate the diagnosis of N17.9. 
 
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 diagnosis code N17.9, defined as acute kidney 
failure, unspecified. 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 billing of diagnosis code N17.9 is not 
supported. Our physician reviewer found the provided records do not clearly document a creatinine increase to 
greater than or equal 1.5 times baseline value within the prior seven days, or a decrease in urine volume to <0.5 
mL/kg/hour over six hours as is generally accepted for the definition of acute kidney failure. Therefore, the 
reviewer found that the billing of diagnosis code N17.9 is not supported in the record.  
 
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 from March 11, 2021, to March 12, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies (A4362, A4369, A4389, A5057) provided 
on January 9, 2023. 
 
You asked the Plan to pay for the medical supplies. You say that these items were medically necessary. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain an itemized proof of delivery. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for medical supplies (A4362, A4369, A4389, A5057) provided on January 9, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 2, 2022, to 
March 31, 2022. 
 You asked the Plan to pay for the home health services. You say that these services do not require prior 
authorization. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 2, 2022. The NOA was not received by the Plan until May 5, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
March 2, 2022, to March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services (code 99232) provided on January 18, 
2023. 
 
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says your claim 
was billed with diagnosis codes that should not be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate diagnosis codes. Diagnosis codes with an Excludes1 note cannot be billed together. 
 
In this case, we find that CPT code 99232 is not correctly billed. Specifically, diagnosis codes E11.621 (Type 2 
diabetes mellitus with foot ulcer) and E08.621 (diabetes mellitus due to underlying condition with foot ulcer) 
were reported together. The ICD-10-CM files show these diagnosis codes as having an Excludes1 note. Based 
on this information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for the physician services (code 99232) provided on 
January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA) (64624). 
 
You asked the Plan to pre-approve genicular RFA. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 genicular RFA. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found RFA of the genicular nerves is the subject of ongoing clinical trials and is considered 
experimental. Therefore, the request is deemed not medically reasonable and 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 genicular RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular radiofrequency ablation (RFA) (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 1, 2023. 
 
You asked the Plan to pay for the medical services. You say that the diagnoses billed are payable. The Plan 
denied your request. The Plan says you billed two diagnoses on this claim that should not be reported together. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis codes with an Excludes1 note indicates 
that the code excluded should never be used at the same time as the code above the Excludes1 note. 
 
In this case, you billed this claim with diagnoses of R06.00 and J96.01. Code J96.01 is an Excludes1 code 
under code R06.00, so these two diagnoses cannot be billed together. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided on January 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service August 10, 
2022.  
 You asked the Plan to pay for procedure code 86077. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service January 22, 2023. 
 
You asked the Plan to pay for code 99285. You say that this service was medically necessary. The Plan denied 
your request. The Plan says billed code 99285 was not supported by the medical record. This code was down-
coded to code 99284 based on the medical records. 
 
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  Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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 code 99285. Our reviewer says that code 99285 is not 
supported by the medical record. Our reviewer found the enrollee is a 94-year-old female with a history of 
Dementia, hypertension, hyperlipidemia, and a known brain tumor who presented to the emergency room with 
mental status changes. The evaluation revealed evidence of a urinary tract infection and elevated troponins. 
Computed tomography of the brain revealed the known brain tumor but no acute findings. She was treated with 
IV Rocephin and acetylsalicylic acid and admitted. The review has determined that the documentation did not 
support procedure code 99285. Specifically, there was no medical decision making 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 code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service January 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for an office visit provided on November 30, 2022. 
 
You asked the Plan to pay the full cost for an office visit. You say that you are being billed too much for this 
service. The Plan denied your request. The Plan says the allowed amount for this service has been  
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an office visit have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed amount as 
payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare 
allowed payment. Therefore, we decided that the Plan does not have to pay the full cost for an office visit 
provided on November 30, 2022.