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

 
We decided that the Plan does not have to pay for practitioner services provided on May 4, 2023, billed with 
procedure code 99232. 
 You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis code at issue is not appropriate as a 
primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code F05, described as 
delirium due to known physiological condition. This code is not an appropriate primary diagnosis as the code 
has a code first note indicating to code the underlying condition first. Based on this information, we decided 
that Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan does not 
have to pay for practitioner services provided on May 4, 2023, billed with procedure code 99232.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95870 and 95970 provided on March 2, 
2023. 
 You asked the Plan to pay for procedure codes 95870 and 95970. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the codes billed cannot be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes  95870 and 95970 are not supported in the medical record. Specifically, these codes 
are included in code 95869 which was also billed. Based on this information, we decided that Medicare rules 
for coverage of procedure codes 95870 and 95970 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 95870 and 95970 provided on March 2, 2023.
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 March 15, 
2023.  
 
You asked the Plan to pay for procedure code 99232. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99232 is bundled into payment for code 
99233. 
 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 99232 
is a column two code to column one code 99233 with a modifier indicator of 0. The column two code is 
therefore not payable. 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 99232 billed for date of service March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of initial hospital care (99223) provided on 
May 5, 2022. 
 
You asked the Plan to pay for a second unit of initial hospital care. You say that this should be reprocessed. 
The Plan denied your request. The Plan says a second unit is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that a second unit of CPT code 99223 are not supported in the medical record. The medical record 
only supports one unit of CPT code 99223, which was previously billed and paid. Based on this information, 
we decided that Medicare rules for coverage of a second unit of initial hospital care have not been met. 
Therefore, we decided that the Plan does not have to pay for a second unit of initial hospital care (99223) 
provided on May 5, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for practitioner services provided on December 28, 2022, billed with 
procedure code 99358. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says that the billed code has a status indicator I and is 
not valid for Medicare purposes. 
 
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. We have found that on the date of service in question, the billed code did not 
have a status I indicator per Centers for Medicare and Medicaid Services. As such, the Plan's rationale for 
denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for practitioner services 
provided on December 28, 2022, billed with procedure code 99358.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator and portable oxygen equipment 
provided on June 25, 2023. 
 
You asked the Plan to pay for the oxygen concentrator and portable oxygen equipment. You say that you were 
unaware that there was a $2,500 limit on coverage provided out-of-state. The Plan denied your request. The 
Plan says based on claims history you have met your annual limit. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication. 
 
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 oxygen concentrator and portable 
oxygen equipment Our reviewer says that these items were not medically necessary. Our physician reviewer 
found there is no documentation data or evidence that home oxygen is required. 
 
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 oxygen concentrator and portable oxygen equipment have not been met.  
Therefore, we decided that the Plan does not have to pay for an oxygen concentrator and portable oxygen 
equipment provided on June 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit for a new patient (99202) billed for date of 
service July 26, 2023. 
 
You asked the Plan to pay for a new-patient visit. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the case record does not support the service 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 99202 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 straightforward medical decision making. When using time for code selection, 15-29 minutes 
of total time is spent on the date of the encounter. 
 We find that CPT code 99202 is not supported in the case record. Specifically, the Plan has documented that 
the enrollee is not a new patient to the practice. Based on this information, we decided that Medicare rules for 
coverage of a new-patient visit have not been met. Therefore, we decided that the Plan does not have to pay for 
an office visit for a new patient (99202) billed for date of service July 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6219 and A6196 billed for date of service 
July 19, 2023. 
 
You asked the Plan to pay for procedure codes A6219 and A6196. You say that you disagree with the denial. 
The Plan denied your request. The Plan says procedure codes A6219 and A6196 are considered 
bundled/excluded 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 codes A6219 and A6196 have a status indicator of P on the Physician Fee Schedule. 
This means that procedure codes A6219 and A6196 are not separately payable/excluded from coverage. Based 
on this information, we decided that Medicare rules for coverage of procedure codes A6219 and A6196 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A6219 and A6196 
billed for date of service July 19, 2023.
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. You say that the enrollee is a recent amputee as they were 
amputated above their right knee and the enrollee needs to learn how to become mobile. The Plan denied your 
request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the 
requirements for approval.  
 
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. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the chest, neck, spine, and upper gastrointestinal 
tract billed with codes 71045, 74230, 74240, 72040 provided on February 24, 2023. 
 
You asked the Plan to pay for the x-rays. You say that medical records submitted supports Current Procedure 
Code (CPT) codes 70100, 72040, 70310, 74230 and should be paid. The Plan denied your request. The Plan 
says POS 11 (office setting) was billed, however, documentation received does not support that the services 
were performed in an office setting but rather in a mobile setting at a skilled nursing facility (SNF). 
 
Medicare rules say that for services in a mobile unit, the POS code assigned should either be the POS code for 
the entity the mobile unit is serving, or POS code 15. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the x-
ray of the chest, neck, spine, and upper gastrointestinal tract billed with codes 71045, 74230, 74240, 72040 
provided on February 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Spinal Simplicity interspinous-interlaminar fusion 
device (Minuteman device). 
 
You asked the Plan to pre-approve the Minuteman device. You say that the enrollee is in severe pain. The Plan 
denied your request. The Plan says use of this device as a stand-alone procedure has not been shown to be safe 
and effective in long term studies. 
 
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 Minuteman device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the HA Minuteman G3-R MIS Fusion Plate is intended for use with bone graft 
material and is not intended for stand-alone use. In addition, fusion indications within guidelines/literature for (existing or potential intraoperative) instability have not been documented and/or met in this case. In addition, 
there are multiple alternate pain generators plausibly significantly contributing to the clinical condition that 
have not been fully documented as having been excluded and/or ruled out. No compelling rationale is 
presented, or extenuating circumstances noted to support the medical necessity of this request as an exception. 
Therefore, the requested Spinal Simplicity interspinous-interlaminar fusion device (Minuteman Device) 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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Spinal Simplicity interspinous-interlaminar fusion device (Minuteman 
device).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77062 billed for date of service May 31, 
2023. 
 
You asked the Plan to pay for procedure code 77062. You say that medical records submitted support code 
77062 and should be paid. 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 77062 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77062 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77062 billed for date of service May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until May 10, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81284 billed for date of service March 14, 
2023. 
 You asked the Plan to pay for procedure code 81284. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 81284 is bundled into payment for 
code 81286. 
 
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 81284 
is a column II code to column I code 81286. 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 81284 billed for date of service March 14, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration for 
the continuation of home health services. The Plan denied your request. The Plan says the services are not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the enrollee 
does not have documented skilled nursing needs. The enrollee is functioning at a level commiserate with a 
lower level of 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service July 19, 
2023.  
You asked the Plan to pay for procedure code 99497. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says payment for code 99497 is bundled into payment for 
code 99223. 
 
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 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99497 billed for date of service July 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for End-stage renal disease (ESRD) related services (90960) 
provided on June 1, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the End-stage renal disease (ESRD) related services. You say that this service 
was medically necessary. The Plan denied your request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for End-stage renal disease (ESRD) related services (90960) provided on 
June 1, 2023, by an out-of-network (OON) provider.
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. You say that you request that the acute inpatient rehab services be 
overturned in order for the enrollee to regain their maximum function. The Plan denied your request. The Plan 
says the inpatient rehabilitation facility (IRF) services you are requesting do not meet the requirements for 
approval.  
 
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. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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.