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

 
We decided that the Plan has to pay for inpatient care provided on May 27, 2022 to June 14, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that the records do not support the Diagnosis Related Group (DRG) billed. 
 
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. The plan has argued that the medical records do not support the billed DRG, 
however the plan did not provide the actual medical records for review. Only the plan's clinical rationale and 
medical literature were provided. Without the actual clinical records for this patient, the denial cannot be 
supported. Therefore, we decided that the Plan has to pay for inpatient care provided on May 27, 2022 to June 
14, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99253 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for procedure code 99253. You say that you disagree with the denial. 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 99253 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code 99253 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 99253 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99253 billed for date of service October 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anterior instrumentation (22846-59) provided on January 25, 
2022. 
 
You asked the Plan to pay for 22846-59. You say that you are appealing this denial. The Plan denied your 
request. The Plan says code 22846-59 is not supported as a separately payable service. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the record does not support that additional separate instrumentation was placed. Based on 
this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not 
been met.  Therefore, we decided that the Plan does not have to pay for anterior instrumentation (22846-59) 
provided on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; peripheral nerve (64555). 
 
You asked the Plan to pre-approve the peripheral nerve stimulation. You say that the requested device is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested device 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 the peripheral nerve stimulation. Our 
reviewer says that the requested peripheral nerve stimulation is not considered medically reasonable and 
necessary in this case.  Our physician reviewer found the requested service is considered an experimental 
therapy for knee pain. Therefore, the reviewer found that the requested service 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 the peripheral nerve stimulation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode array; 
peripheral nerve (64555).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient surgical services rendered on January 2, 2023, to January 
3, 2023. 
 
You asked the Plan to pay for these services. You say that you needed emergency gallbladder surgery while out 
of state. The Plan denied your request. The Plan says that the claim was billed with bill type 130, indicating a 
nonpayment/zero claim. 
 
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. The Plan states that the claim was billed with anticipation of no payment by the 
provider; however, the documentation shows that you needed emergency surgery with an inpatient admission 
while outside of the Plan's service area. The contract with the Plan states that you have coverage for out-of-
network inpatient care and worldwide coverage for emergency care. The Plan has not provided any 
documentation or binding Medicare rules to support that the services cannot be covered. Therefore, we decided 
that the Plan has to pay for the inpatient surgical services rendered on January 2, 2023, to January 3, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Incobotulinumtoxin A injection (Xeomin). 
 
You asked the Plan to pre-approve Xeomin. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Xeomin. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a diagnosis of chronic skin ulcers secondary to Raynaud's syndrome and 
unspecified systemic sclerosis. The Food and Drug Administration has not stated that the requested drug is 
indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation.  Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xeomin have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Incobotulinumtoxin A injection (Xeomin).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service July 27, 
2022. 
 You asked the Plan to pay for procedure code 99222. You say that you are appealing with supporting medical 
records. The Plan denied your request. The Plan says payment for code 99222 is bundled into payment for code 
36556. 
 
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 99222 
is a column II code to column I code 36556. 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 99222 billed for date of service July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service December 
24, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service December 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the psychotherapy services provided from June 1, 
2022, to December 31, 2022. 
 
You asked the Plan to reimburse you for the psychotherapy services. You say that you would like to be 
reimbursed for these services. The Plan denied your request. The Plan says the provider is not Medicare 
certified and therefore cannot be paid. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the psychotherapy services 
provided from June 1, 2022, to December 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital evaluation and management (EM) services 
provided on July 20, 2022, and July 21, 2022, billed with code 99233. 
 
You asked the Plan to pay for the EM services as billed. You say that the services were correctly billed.  The 
Plan denied your request. The Plan says the records do not support the billed services.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
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 EM services as billed. Our reviewer says 
that the records do not support the billed codes.  Our reviewer found the member is an 84-year-old female with 
a medical history including hypertension who was admitted to the hospital after a fall resulted in a fractured 
hip. The member was treated surgically and remained medically stable. She had some postoperative anemia 
that required a blood transfusion on July 21, 2021, and she was monitored for hyponatremia. The 
documentation available for review does not indicate she was unstable at any time. The documentation does not 
support a comprehensive history was obtained at the time of these two encounters, nor was there a detailed 
interval history or examination. 
 
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 EM services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the hospital evaluation and management (EM) services provided on July 20, 
2022, and July 21, 2022, billed with code 99233.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided on October 14, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and are 
supported in the medical records. The Plan denied your request. The Plan says that this claim is denied as 
additional information 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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, additional documentation has been provided since the initial denial. 
The Plan has not provided an updated reason for denial in this case, and this reason has not been supported with 
evidence and a relevant citation. Therefore, we decided that the Plan has to pay for laboratory services provided 
on October 14, 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 an Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has 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 the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case.  Our 
physician reviewer found this procedure is considered investigational at this time. More research is needed to 
show safety and efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the test Know Error DNA Specimen Provenance Assay 
(DSPA) (81266, 81265) provided on August 4, 2022. 
 
You asked the Plan to pay for the DSPA testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this test should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the DSPA testing have not been met. 
Therefore, we decided that the Plan does not have to pay for  the test Know Error DNA Specimen 
Provenance Assay (DSPA) (81266, 81265) provided on August 4, 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 30, 2022 to 
September 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. 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 30, 2022 to 
September 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service December 2, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service December 2, 2022, billed 
with code 99153.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on October 11, 
2022. 
 
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 October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99204 billed for December 20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99204 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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter. 
 
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 these services. Our reviewer says that procedure code 99204 is not supported. Our reviewer found the enrollee was evaluated on December 20, 2022 with 
electromyelography (EMG) studies for bilateral hand numbness. The records support a medically-appropriate 
history and examination but do not support medical decision making of moderate 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99204 billed for December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64483 billed for date of service October 18, 
2022.  
 You asked the Plan to pay for procedure code 64483. You say that this is a facility claim, so separate payment 
is allowed. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 64483 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 64483 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 64483 billed for date of 
service October 18, 2022.