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

 
We decided that the Plan does not have to pay for procedure codes 99306 and 99309 rendered from November 
3, 2022, to November 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
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 the denied codes is: 
 
CPT 99306: 
 
Initial nursing facility 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. 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 problem(s) requiring admission are of high severity. Typically, 45 minutes are 
spent at the bedside and on the patient's facility floor or unit 
 
CPT 99309: 
 
Subsequent nursing facility 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 moderate 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 has developed a significant complication or a significant new 
problem. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports a 
comprehensive exam, but not a comprehensive history or medical decision making of high complexity or 45 
minutes spent on the service, so CPT 99306 is not supported. 
 
Additionally, the documentation supports an appropriate exam, but not an appropriate interval history or 
medical decision making of moderate level or 25 minutes spent on service, so CPT 99309 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 99306 and 99309 rendered from November 3, 2022, to November 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services described by codes 74230, 74240, 
70100, 72040, and 70310 performed on March 13, 2023. 
 
You asked the Plan to pay for the radiology services. You say that the radiology services should be covered as 
is because they were medically necessary and are supported in the documentation. The Plan denied your 
request. The Plan says the radiology services described by codes 74240 and 74230 are not covered benefits 
because they are listed in the Exclusions from Coverage as Portable X-Ray Services section of the Medicare 
Benefit Policy Manual. The Plan says the radiology services described by codes 70100, 72040, and 70310 were 
billed with an inappropriate place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology services performed in the mobile 
setting are not eligible for reimbursement if they are listed in the Exclusions from Coverage as Portable X-Ray 
Services section of the Medicare Benefit Policy Manual. Medicare rules also state that claims must be billed 
with the appropriate POS.  
 
We looked at the file and Medicare rules. Documentation provided shows codes 74240 and 72430 were 
performed in a mobile unit setting with the use of fluoroscopy. Therefore, they are not covered and are 
excluded under the portable x-ray provision. Codes 70100, 72040 and 70310 were billed with POS 11, 
indicating an office setting. However, documentation shows the radiology services were performed in a mobile 
setting. There is no evidence the services were provided in an office setting. Based on this information, we 
decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiology services described by codes 74230, 74240, 70100, 72040, 
and 70310 performed on March 13, 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 would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. 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 clinical 
documentation does not specify any acute clinical status changes, change in medication or care plan that would 
be expected to require home health skilled nursing thus the records do not show that skilled nursing services 
would be required in the home setting. 
 
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 a facility visit provided on February 20, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this was medically necessary. You depend on the 
facility to get proper paperwork for these visits. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a facility visit provided 
on February 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced foot (L5981). 
 
You asked the Plan to pre-approve an advanced foot. 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 follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria 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 an advanced foot. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the physician documentation states 
the patient is a K2 ambulator and does not support the prosthetist's claims of the patient's need for the requested 
advanced foot. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an advanced foot have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an advanced foot (L5981).
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 could be harmed at a lower level of care 
without adequate medical supervision management and their best outcome for functional gains are at an IRF 
location. The Plan denied your request. The Plan says the enrollee's conditition does not meet the Medicare 
guidelines for admission to an IRF.  
 
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 clinical documentation does not specify any active medical comorbidities or 
complex functional impairments. Thus the complexity of the enrollee's documented nursing, medical, and 
rehabilitation needs would not be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. Clinical documentation shows that the enrollee requires ongoing physical 
therapy and occupational therapy but does not support the medical necessity of an an IRF setting.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on February 2, 
2023. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported as 
billed. The Plan denied your request. The Plan says there is insufficient information to support these services. The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing have been met. 
Specifically, the records provided do not include a signed physician order detailing the requested drugs for 
testing. Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0483) provided 
on February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive hearing evaluation 
provided on April 05, 2023. 
 
You asked the Plan to waive the copayment for a comprehensive hearing evaluation. You say that you were 
getting a hearing test for hearing aids. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for Medicare-covered diagnostic hearing exams. 
 
You have been asked to pay a $15 copayment for a comprehensive hearing evaluation. This item/service falls 
within the Medicare-covered diagnostic hearing exams benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for a comprehensive hearing evaluation provided on April 05, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for the outpatient mental health services provided on 
April 5, 2023. 
 
You asked the Plan to further pay for the billed services. You say that previous payments have been paid in 
full. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for out-of-network outpatient mental health services.  
 
The file shows that you received services from an out-of-network provider. You were reimbursed the total 
amount minus the 20% coinsurance. The services fall within the outpatient mental health services benefit 
category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to further pay for the outpatient mental health services provided on April 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thrombectomy and angioplasty of arteriovenous fistula 
services (36905) provided on December 15, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the thrombectomy and angioplasty of arteriovenous fistula services . You say 
that you tried to request authorization through the provider portal prior to the procedure and received a 
response that no authorization was required.  The Plan denied your request. The Plan says they require 
utilization of network providers when possible and available. The Plan says that no medical necessity for an 
OON provider, such as an urgent or emergent situation, was documented.   
 
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. While the Plans online procedure 
code inquiry said that the code being billed did not statutorily require prior authorization, it also advised that 
prior authorization requirements vary by benefit Plan and the providers participation status. The Plan had 
network providers available who could have provided the services at issue in this appeal. The Plan did not pre-
approve the services at issue. We found no exception that would require the Plan to pay for these OON 
services. Therefore, we decided that the Plan does not have to pay for the thrombectomy and angioplasty of 
arteriovenous fistula services (36905) provided on December 15, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87798) provided on March 9, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not 
support the billed code and units. 
 
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 87798 is "Infectious agent detection by nucleic acid 
(DNA or RNA), not otherwise specified; amplified probe technique, each organism". 
 
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 the services. Our reviewer says that the use of code 87798 is 
not supported by the records provided. Our reviewer found that the medical record does not include 
documentation to support the specific procedures billed with a not otherwise specified procedure code. Therefore, the billed procedure code and units billed cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (87798) provided on March 9, 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 you would benefit a lot and gain more strength to 
manage yourself. The Plan denied your request. The Plan says these services are not medically necessary.  
 
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. You do 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 you 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the DecisionDx-SSC test (0315U) provided March 15, 2023. 
 
You asked the Plan to pay for  the laboratory service. You say that your claim for the DecisionDx-SCC test was 
denied in error and you are requesting it be reprocessed ad paid. The Plan denied your request. The Plan says 
the requested test is not medically reasonable or necessary and is therefore not approved. 
 
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. The use of molecular tests such as DecisionDx-SCC are not 
considered standard of care for determining treatment of squamous cell carcinoma. Its use is not supported by National Comprehensive Cancer Network (NCCN) guidelines or the medical literature. In addition, per the 
Plan's policy Proprietary Laboratory Analyses (PLA) Codes, 0315U is listed as a PLA noncovered due to 
experimental/ investigational status. 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-SSC test (0315U) provided March 15, 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 services are medically necessary for the enrollee 
to receive the therapy services needed as they are not receiving the care needed in their current facility. The 
Plan denied your request. The Plan says the enrollee records do not show that they need an intensive team for 
their 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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for skilled nursing facility (SNF) care provided 
from March 1, 2023, to March 31, 2023. 
 You asked the Plan to pay the full cost for SNF care. You say that this should be fully covered because your 
discharge was delayed. The Plan denied your request. The Plan says this cost sharing was charged correctly, 
and a claim or itemized bill has not been received for the other dates of service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $196 
copayment per day for days 21 to 100 for skilled nursing facility (SNF) care. Medicare rules also say that the 
provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient 
information to determine whether payment is due and the amount of payment. 
 
You have been asked to pay a $196 copayment per day for days 21-27 of the SNF stay that began on February 
16, 2023, for a total of $1,179 ($196 per day x 6 days = $1,176). This item/service falls within the skilled 
nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The dates of service from March 14, 2023, to March 31, 2023, are not covered because no 
itemized bill or claim has been submitted for these dates. Therefore, we decided that the Plan does not have to 
pay the full cost for skilled nursing facility (SNF) care provided from March 1, 2023, to March 31, 2023.