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

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service July 5, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code is 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of high complexity. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the records do not include a 
comprehensive history. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99223 
billed for date of service July 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for dates of service February 28, 2022, 
to March 21, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the diagnosis 
code is inconsistent with the enrollee's age. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that the lab testing was billed with diagnosis code Z36.89. This diagnosis code is applicable to 
maternity patients aged 12-55 years. The records do not show the enrollee meets the criteria for this billed 
diagnosis. Based on this information, we decided that Medicare rules for coverage of the billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for dates of 
service February 28, 2022, to March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment with bupivacaine (J3490) provided on March 31, 
2023. 
 You asked the Plan to pay for bupivacaine. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says payment for bupivacaine is included in the global package of 
procedure code 27096. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (27096) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for treatment with bupivacaine (J3490) provided on March 31, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospitalization care provided from September 
12, 2022, to September 13, 2022. 
 You asked the Plan to pay for the inpatient hospitalization care. You say that the Plan has inappropriately 
denied this claim. The Plan denied your request. The Plan says the medical records provided do not have any 
documentation of any complication or medical instability following surgery to support a reasonable expectation 
that the patient would require an inpatient hospital stay extending beyond 2 midnights. 
 
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 the inpatient hospitalization care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee was clinically stable and was not expected to require hospital 
services that would likely have crossed 2 midnights.  
 
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 inpatient hospitalization care have not been met. Therefore, we decided that 
the Plan does not have to pay for the inpatient hospitalization care provided from September 12, 2022, to 
September 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from June 28, 2022, to July 
27, 2022. 
 You asked the Plan to pay for the home health services. You say that you sent in the required NOA. The Plan 
denied your request. The Plan says although you contend the NOA was submitted, no NOA is on file. 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 required NOA has not been received by the Plan. As a result, 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 June 
28, 2022, to July 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6413 billed for date of service September 
20, 2022. 
 
You asked the Plan to pay for procedure code A6413. You say that you have billed the item at issue correctly. 
The Plan denied your request. The Plan says the billed code is not covered by Medicare.  
 
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 A6413 has a Status Indicator of N on the Physician Fee Schedule. This means that procedure code A6413 is not covered by Medicare. Based on this information, we decided that Medicare rules 
for coverage of procedure code A6413 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A6413 billed for date of service September 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's 
medical condition does not require physician evaluation and supervision three times a week. Services needed 
may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation services identified with code G0283 
and the injection services identified with code 96372 for date of service August 18, 2022. 
 
You asked the Plan to pay for the electrical stimulation services and the injection services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that electrostimulation for the treatment of multiple 
neuropathies or peripheral neuropathies caused by underlying systemic diseases is not considered medically 
reasonable and necessary. 
 
We looked at the file and Medicare rules. Review of the file shows that injections provided with electrical 
stimulation services are specifically not covered. Based on this information, we decided that Medicare rules for 
coverage of the electrical stimulation services and the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation services identified with code G0283 
and the injection services identified with code 96372 for date of service August 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 25, 2022, to 
September 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct date of 
service. 
 
The Plan follows Medicare rules. The rules say that home health claims are paid based on a 30-day period of 
care.  
 
 
 
 We reviewed the file and the Medicare rules. We find that the date of service was not billed correctly. The 
"through" date should be 29 days after the "from" date. Based on this information, we find that the Medicare 
rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from August 25, 2022, to September 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code A4223 billed for date of service March 11, 2023, to 
March 15, 2023.   
You asked the Plan to pay for code A4223. You say that you disagree with the Plan's denial. 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 A4223 is 0. The MAI value for this code is 3. You billed 5 units of this 
code, exceeding the MUE. 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 A4223 have not been met. Therefore, we decided that the 
Plan does not have to pay for code A4223 billed for date of service March 11, 2023, to March 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TissueCypher Barrett's Esophagus test (0108U) provided 
on December 29, 2022. 
 
You asked the Plan to pay for the TissueCypher Barrett's Esophagus test. You say that this test is a covered 
benefit. The Plan denied your request. The Plan says this test remains unproven for determining the risk of 
progression from Barrett's esophagus to high grade dysplasia or 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 TissueCypher Barrett's Esophagus test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that TissueCypher is not endorsed by national clinical guidelines and is 
not medically necessary in this case. 
 
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 TissueCypher Barrett's Esophagus test have not been met. Therefore, we 
decided that the Plan does not have to pay for the TissueCypher Barrett's Esophagus test (0108U) provided on 
December 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on November 23, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 November 23, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 25, 2023, to 
March 17, 2023. 
 You asked the Plan to pay for the home health services. You say that this claim incorrectly denied for no NOA. 
The Plan denied your request. The Plan says although you claim that the NOA was provided, no NOA has been 
received. 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 NOA was not received by the Plan. As a result, 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 January 25, 
2023, to March 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on March 17, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on March 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with single power 
option (K0856) and additional items and accessories (codes E0955, E0956, E1002, E1028, E2361, E2603, 
E2620, and K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
The Plan denied your request. The Plan says the enrollee does not have a medical need for a single power 
option included with a K0856 group 3 power wheelchair. 
 The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with single power option (such as 
code K0856) is covered if the criteria listed in the Medicare rules section of this letter 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 a group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee does not have high risk for skin breakdown, use a catheter 
intermittently, have spasticity or require an alternative means of managing power drive. 
 
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 group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with single power option (K0856) and additional items and accessories (codes E0955, E0956, 
E1002, E1028, E2361, E2603, E2620, and K0040).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of a peripheral nerve. 
 
You asked the Plan to pre-approve RFA. You say that the enrollee has a history of bilateral shoulder 
impingement for approximately six years. The Plan denied your request. The Plan says the 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 RFA. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the literature states that shoulder radiofrequency ablation (RFA) may provide a 
safe and significant benefit in the management of chronic shoulder pain; however, at this time this procedure is 
considered experimental/investigational as there is insufficient evidence that this procedure improves health 
outcomes. The review has determined that the service at issue in this case 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA) of a peripheral nerve.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 19, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test provided October 17, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the DecisionDx-SCC test was denied in 
error, and you are requesting be reprocessed and paid. The Plan denied your request. The Plan says this test is 
considered experimental and investigational. 
 
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. There is insufficient peer-reviewed evidence of an outcome benefit 
associated with this test. 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 
DecisionDx-SCC test provided October 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says  you don't meet all 
the requirements for admission. The Plan says that the services needed may be provided safely in a lower level 
of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64461 billed for date of service January 14, 
2023. 
 You asked the Plan to pay for procedure code 64461. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 64461 is bundled into payment for code 00528. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 64461 
is a column II code to column I code 00528. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 64461 billed for date of service January 14, 
2023.