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

 
We decided that the Plan has to pay for the anesthesia services (01992) provided on June 10, 2022. 
 
You asked the Plan to pay for the anesthesia services . You say that the claim should be paid. The Plan denied 
your request. The Plan says that they do not consider any portion of this anesthesia service as a Reasonable 
Charge because the service is incidental to the procedure performed. 
 
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 did not provide documentation to show that this code was incidental to 
another service and the Plan did not show they actually paid the service code 01992 is incidental to. Therefore, 
we decided that the Plan has to pay for the anesthesia services (01992) provided on June 10, 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 codes 96365, 96366, and 96521 billed for date of 
service April 5, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for diabetes problems. The 
Plan denied your request. The Plan says the billed services are 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. 
 
 
We find that CPT codes 96365, 96366, and 96521 are not supported in the medical record. Specifically, there is 
a more accurate code that describes the services provided, identified by codes 96365 and 96366. The records do 
not show that code 96521 was not provided as billed.  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 codes 96365, 96366, and 96521 
billed for date of service April 5, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base 
to mid-thigh rendered on January 25, 2023. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found that the dictated 
indication for the PET/CT done on 1/25/23 was "restaging melanoma." The dictated indication is not a valid 
ICD-10 code which is necessary for proper billing and coding. Specifically, the site including laterality of the 
original melanoma would have been necessary in order to attach a proper diagnostic code. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for positron emission tomography (PET) with concurrently acquired computed tomography (CT) 
for attenuation correction and anatomical localization imaging; skull base to mid-thigh rendered on January 25, 
2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 25, 2022, to 
October 24, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe this claim should be 
reconsidered. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 25, 2022. The NOA was not received by the Plan until 
December 30, 2022. As more than 30 days passed between the timely filing date and the NOA receipt, no 
payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health 
services provided from September 25, 2022, to October 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 11, 2021, to 
August 16, 2021, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you 
have billed the services at issue correctly. The Plan denied your request. The Plan says principal diagnosis code 
A41.89 is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.89, defined as Other 
specified sepsis. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital 
services at the DRG originally billed. Our reviewer says that the services at issue do not meet criteria for 
payment at the DRG originally billed. Our physician reviewer found that the chronically ill enrollee was 
evaluated for known pleural effusions and known anemia. The enrollee's pleural effusion was drained and 
found to contain malignant cells. There is no evidence that the enrollee had systemic symptoms due to an 
infection (i.e., hypotension, hypoperfusion, organ failure). A diagnosis of sepsis is not supported.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on August 11, 2021, to August 16, 2021, at the DRG originally billed.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on March 30, 2023. 
 
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 Current Procedural Terminology (CPT) code 99285 remains 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making." 
 
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 an 
appropriate exam, but not an appropriate history or medical decision making of high level. 
 
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 emergency room services (procedure code 99285) rendered on March 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor.  
You asked the Plan to pre-approve a FreeStyle Libre 2 sensor. You say that the enrollee needs this as soon as 
possible. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a FreeStyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a FreeStyle Libre 2 sensor.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care billed for dates of service June 17, 2022, to 
July 2, 2022. 
 
You asked the Plan to pay for the billed services. You say that hospice was terminated prior to admission to the 
facility. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
For dates of service June 17-30, 2022, the enrollee ended Medicare Hospice benefits on June 7, 2022. The 
services in question were provided before the end of that month. Original Medicare is responsible for payment 
for services until the first day of the month after the hospice election has been revoked. For dates of service 
July 1-2, 2022, hospice claims should not span multiple months. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the inpatient care billed for dates of service June 17, 2022, to July 2, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on February 14, 2023. 
 
You asked the Plan to pay for the 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 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 presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function". 
 
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 99285 is 
not supported by the records provided. Our reviewer found that the provided records document a general 
multisystem examination. The records do not document 2 out of 3 of an extensive number of diagnoses or 
management options, an extensive amount and complexity of data reviewed, or high risk of complication. 
 
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 (99285) provided on February 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99285) provided on August 8, 2022. 
 
You asked the Plan to pay for the 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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function".  
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 99285 is 
not supported by the records provided. Our reviewer found that the emergency department visit supports a 
comprehensive exam and history and medical decision making of low complexity. There is a more appropriate 
code to report for the service provided in this case. 
 
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 (99285) provided on August 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance (eg, proton) imaging (MRI), spinal 
canal and contents, thoracic; without contrast material (72146) provided on January 26, 2023. 
 
You asked the Plan to pay for the MRI. You say that the diagnosis code was appropriate for the date of service. 
The Plan denied your request. The Plan says the diagnosis codes associated to M54.2 and M50.320 should not 
be reported together. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the MRI have not been met. The billed Service 72146 was denied 
because the diagnosis codes associated to M54.2 and M50.320 should not be reported together. The billed 
service has been denied because it was reported with one or more diagnosis code pairs that are subject to an 
Excludes1 note. Therefore, we decided that the Plan does not have to pay for the magnetic resonance (eg, 
proton) imaging (MRI), spinal canal and contents, thoracic; without contrast material (72146) provided on 
January 26, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on November 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided on November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection.  
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection 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 injection. Our reviewer says that the 
enrollee does not meet the coverage criteria. Our physician reviewer found that the enrollee reported 70% pain 
relief with the prior interlaminar epidural steroid injection on June 28, 2023, eighteen days after the injection. 
The coverage criteria require at least 50% improvement in pain relief or function for at least 3 months. Since it 
has not been three months since the last injection the requested epidural steroid injection is not medically 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for closed treatment of post hip arthroplasty dislocation; requiring regional 
or general anesthesia rendered on December 7, 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 that Current Procedural Terminology (CPT) code 27266-RT remains 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 27266 is "Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia." 
 
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 supported by the medical records. Our reviewer found that the records do support that CPT 
27266: closed treatment of post-hip arthroplasty dislocation, requiring regional or general anesthesia was 
rendered in this case. A hip reduction was performed. He was sedated with propofol using the procedural 
sedation protocol. The hip was reduced with traction and countertraction. There were no complications. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia rendered on 
December 7, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (procedure code 99285) rendered 
on August 5, 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 clinical information included with appeal did not include a presenting problem of high 
severity/ immediate significant threat for life or physiological function. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 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 presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
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. The 
records do not support the presenting problems were of high severity, posing an immediate threat to life and 
function. 
 
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 emergency room services (procedure code 99285) rendered on August 5, 2022.