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

 
We decided that the Plan does not have to pay for procedure codes 93283, 93613, 93656, 93657, 93662 and 
99220 billed for date of service February 8, 2022. 
 
You asked the Plan to pay for procedure codes 93283, 93613, 93656, 93657, 93662 and 99220. You say that 
you have billed the services at issue correctly. The Plan denied your request. The Plan says the provided 
records do not support the services 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 93656 is: Comprehensive electrophysiologic evaluation 
including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with 
intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac 
electrophysiologic 3-dimensional mapping, intracardiac echocardiography including imaging supervision and 
interpretation, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, 
right ventricular pacing/recording, and His bundle recording, when performed. 
 
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 procedure codes 93613, 93656, 93657, 93662 and 99220. 
Our reviewer says that procedure codes 93613, 93656, 93657, 93662 and 99220 do not meet criteria for 
payment. Our reviewer found that the procedure report does not include sufficient documentation to verify 
procedure code 93656 criteria have been met. Procedure codes 93613, 93657 and 93662 are "add-on" codes 
and require a primary procedure code. In this case, a comprehensive electrophysiologic (EP) study cannot be 
verified in the operative report; therefore, procedure codes 93613, 93657 and 93662 are not supported. You 
reported procedure code 99220 with appended modifier 25, indicating a significant, separately identifiable 
evaluation and management (E/M) service above and beyond that associated with another procedure or service 
being reported by the same physician or other qualified health care professional (QHP) on the same date to 
bypass an Edit with multiple procedures performed. However, the evaluation and management service 
documented does not support a separately identifiable evaluation and management service and therefore 
procedure code 99220 cannot be verified. 
 
Furthermore, we have confirmed that code 93283 is a column II code to column I code 93656 with a modifier 
indicator of 0. The column II code is therefore not payable. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 93283, 93613, 93656, 93657, 93662 and 99220 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 93283, 93613, 93656, 
93657, 93662 and 99220 billed for date of service February 8, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intralesional injections (11900) for the treatment of alopecia. 
 
You asked the Plan to pre-approve intralesional injections. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that the requested services are cosmetic 
in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pre-approve intralesional injections. Our reviewer 
says that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that intralesional steroid injections are a standard of care for the type of scarring alopecia that 
the enrollee has. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intralesional injections have been met. Therefore, we decided that the Plan has 
to pre-approve intralesional injections (11900) for the treatment of alopecia.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared 
for in their current condition at a skill nursing facility as they require direct daily physician assessment, which 
cannot be performed remotely. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements for admission to an LTACH.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is receiving all necessary and indicated care at the acute care 
hospital; there are no specific treatments the enrollee would receive at an LTACH that they are currently not receiving. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
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 your health is decreasing and need this inpatient 
facility. The Plan denied your request. The Plan says your condition does not meet the Medicare guidelines.  
The Plan says that the services needed may be provided safely in a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care 
and does not require transfer to a Long-Term Acute Care Hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
 
 
 
 
 
 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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee continues to have ongoing acute medical issues 
and still requires acute care services. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Confirm MDx testing (81551) provided on February 16, 
2023. 
 
You asked the Plan to pay for the Confirm MDx testing (81551). You say that the provided Confirm MDx 
testing (81551) was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet 
criteria for the provided Confirm MDx testing (81551). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Confirm MDx testing (81551). Our 
reviewer says that the enrollee did not meet criteria for the provided Confirm MDx testing (81551). Our 
physician reviewer found the records do not show that repeat prostate-specific antigen (PSA) is greater than 3 
and less than 10ng/mL AND/OR Digital Rectal Exam (DRE) findings are very suspicious for cancer, and re-
biopsy is being considered. 
 
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 Confirm MDx testing (81551) have not been met. Therefore, we decided 
that the Plan does not have to pay for the Confirm MDx testing (81551) provided on February 16, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 25, 2022, 
to December 13, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that that 
G92.8, G93.41, and E43 are supported in the record, therefore the claim should be paid at the original DRG. 
The Plan denied your request. The Plan says G92.8, G93.41, and E43 are not supported in the record. 
 
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 G92.8, defined as other toxic 
encephalopathy, secondary diagnosis G93.41, defined as metabolic encephalopathy, and secondary diagnosis 
E43, defined as unspecified severe protein-calorie malnutrition. 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 principal 
diagnosis G92.8, secondary diagnosis G93.41, and secondary diagnosis E43 are not supported in the record. 
Our physician reviewer found the documentation does not support G92.8 or G93.41 as there was no objective 
evidence of an acute encephalopathy based on imaging, blood work, or examination. E43 is not supported by 
the documentation as the enrollee did not have physical muscle wasting, there was no report of 10% weight 
loss over the prior 6 months, their BMI was not less than 20, and there was not an assessment of current oral 
food intake being less than 50% of required.  
 
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 November 25, 2022, to December 13, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on January 25, 2023, billed with 
codes 87481, 87798, 87640, 87653, & 87500. 
 
You asked the Plan to pay for the lab testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the lab testing billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on January 
25, 2023, billed with codes 87481, 87798, 87640, 87653, & 87500.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95816 billed for date of service September 5, 
2022. 
 
You asked the Plan to pay for procedure code 95816. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says the provided records do 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 95816 is: Electroencephalogram (EEG); including 
recording awake and drowsy. 
 
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 procedure code 95816. Our reviewer says that procedure code 95816 does not meet criteria for payment. Our reviewer found that the provided procedure report does not 
include sufficient documentation to verify the procedure code has been performed, to include EEG during 
awake and drowsy states. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95816 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95816 billed for date of service September 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified preventive procedure, by report (D1999). 
 
You asked the Plan to pre-approve the unspecified preventive procedure, by report. You say that these services 
are a medical necessity. The Plan denied your request. The Plan says this service is not covered in your dental 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the unspecified preventive procedure, 
by report is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve an unspecified preventive procedure, by report (D1999).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a consultation - diagnostic service provided by dentist or physician 
other than requesting dentist or physician (D9310) provided on June 22, 2023. 
 
You asked the Plan to pay for the consultation. You say that this service was required by the endodontist before 
she would perform the root canal. You also say this was part of the procedure and therefore should be a 
covered expense. The Plan denied your request. The Plan says that the consultation was denied due to the 
frequency limit of one time in a six-month period. 
 
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, the Plan did not provide documentation stating that the limitation of 
a consultation is only provided once every six months. The Plan has not substantiated their denial reason.  
Therefore, we decided that the Plan has to pay for a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on June 22, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) billed for 
dates of service February 17, 2023, to March 2, 2023. 
 
You asked the Plan to pay for code E0217. You say that this item was medically necessary based on medical 
literature. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that water circulating heat pads with pump (E0217) 
are excluded from coverage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code E0217 have not been met. Therefore, we decided that the Plan does not have to pay for the 
water circulating heat pad with pump (E0217) billed for dates of service February 17, 2023, to March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation of the sacroiliac joint. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that that you would benefit from 
another procedure, as the one previously gave you pain relief for a year. The Plan denied your request. The 
Plan says the radiofrequency ablation 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 radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, 
is considered investigational and therefore, 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation of the sacroiliac joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96365 provided on November 8, 2022. 
 
You asked the Plan to pay for procedure code 96365. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the enrollee received services (96365) while in an 
outpatient hospital setting. Per Medicare payment guidelines, code 96365 has a PC/TC indicator of 5 and 
payment may not be made for this code when provided to patients in an outpatient hospital setting. Therefore, 
we decided that the Plan does not have to pay for procedure code 96365 provided on November 8, 2022.