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

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99233) 
rendered from June 20, 2022, to June 21, 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 Current Procedural Terminology (CPT) code 99233 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 99223 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit." 
 
We asked our 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 records do not support this 
level of billing. The records do not document an extended history of present illness, or an extended 
examination of the affected body area (right foot). The records in this case do not document medical decision 
making of high complexity with 2 out of 3 of an extensive number of diagnoses or management options, an 
extensive amount and complexity of data reviewed and 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 evaluation and management services (procedure code 99233) rendered from June 20, 2022, to 
June 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman Procedure (22840, 22612). 
 
You asked the Plan to pre-approve a Minuteman Procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Minuteman Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the minuteman device is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Minuteman Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman Procedure (22840, 22612).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services rendered on May 16, 
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 99495-95 (1 unit) 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 99495 is "Transitional care management services with the 
following required elements: Communication (direct contact, telephone, electronic) with the patient and/or 
caregiver within 2 business days of discharge At least moderate level of medical decision making during the 
service period Face-to-face visit, within 14 calendar days of discharge." 
 
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 enrollee was discharged from 
the hospital on 5/3/2023 where she was treated for headache. The enrollee continued to reported headache on 
5/16/2023 for a follow-up office visit with the doctor, which was within 14 calendar days. It was noted that the 
enrollee was in no acute distress and was alert and oriented. The headache was listed as possible migraine. The 
enrollee was recommended good hydration, regular sleep, and avoiding triggers with a trial of propranolol. The 
provided documentation did not support a moderate level of medical decision making needed to support the 
CPT 99495. 
 
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 transitional care management services rendered on May 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 85060 for April 26, 
2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the 
record shows that the services were not performed for a hospital inpatient. Therefore, we decided that the Plan 
does not have to pay for the laboratory services billed with code 85060 for April 26, 2023.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for 36 units of procedure code A6203. We decided that the Plan does not 
have to pay for 6 units of procedure code A6203.  
 
You asked the Plan to pay for the wound care supplies billed for date of service February 8, 2022. You say that 
the services are separately payable. The Plan says that services are not separately payable when the enrollee is 
an inpatient. 
 
We decided that the Plan has to pay for 36 units of procedure code A6203.  
 
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 denied 36 units stating the enrollee was an inpatient. The Plan has not provided documentation to 
show that the enrollee was receiving covered inpatient services on the date at issue. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for 36 units of procedure code A6203 billed for date of 
service February 8, 2022.  
 
We also decided that the Plan does not have to pay for 6 units of procedure code A6203. 
 
The Plan follows Medicare rules. Medicare rules say that surgical dressings are only covered under certain 
medical indications.  
 
We find that 3 units of code A6203 is allowed per week per wound. The records show that 3 wounds are being 
treated, totaling 36 units. The records do not document why the excess quantities are needed in this case. 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 6 units of procedure code A6203. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) rendered on 
November 3, 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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 unit) 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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed." 
 
We asked our 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 services at issue 
in this case were not supported by the medical records. Our reviewer found that the records provided describe 
the patient had less than 22 drug classes performed. Therefore, the code, G0482 (22+ drug classes) is not 
supported by the documentation. 
 
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 drug testing services (procedure code G0483) rendered on November 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee has horrible COPD with 
shortness of breath. You say that the enrollee needs the machine. The Plan denied your request. The Plan says a 
home ventilator is not medically necessary for this patient because their needs can be met with an alternative 
device such as a BiPAP device with average volume-assured pressure support (AVAPS).   
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The documentation does not 
contain sufficient detailed information in the medical records to justify the selected treatment. Specifically, the 
enrollee could be treated with a BiPAP machine with AVAPS capability, and failure of such a device has not 
been documented. Therefore, the elements of coverage criteria are not satisfied, and the requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 19, 2022, billed with 
codes 87481, 87491, 87563, 87640, 87653, 87798, 87500 and 87641. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 19, 2022, billed with codes 87481, 87491, 87563, 87640, 87653, 87798, 87500 and 
87641.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99236) 
rendered on December 18, 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 Current Procedural Terminology (CPT) code 99236 (1 Unit ) 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 99236 is "Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, 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 presenting problem(s) requiring admission are of high severity. Typically, 55 
minutes are spent at the bedside and on the patient's hospital 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 Our 
reviewer found that the records seem to indicate an emergency department (ED) visit. There is no clear 
evidence of a transition to observation status. Assuming observation level care was provided, the medical 
decision making was not of high complexity. As such, the billing of CPT 99236 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 evaluation and management services (procedure code 99236) rendered on December 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 6, 2022, to 
December 10, 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 you 
have found the secondary diagnosis code J96.01 to be supported by the medical record. The Plan denied your 
request. The Plan says after a thorough review of all the information in the submitted medical record, the 
review did not find sufficient 
documentation to clinically validate the diagnosis of respiratory failure. 
 
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 J96.01- Acute respiratory failure with hypoxia. 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 physician reviewer found the enrollee was hemodynamically stable and was alert and 
oriented. Therefore, the criteria for acute respiratory failure diagnosis is not met and the code, J96.01 is not 
sufficiently supported in the provided documentation for this admission.   
 
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 December 6, 2022, to December 10, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
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 LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for LTACH 
admission. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care.  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevator and electronic connector.

You asked the Plan to pre-approve the accessories. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan follows Medicare rules. Medicare rules say that power seat elevation equipment is reasonable and necessary for individuals using complex rehabilitative power-driven wheelchairs when certain 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 the accessories. Our reviewer says that the requested seat elevator and electronic connector are not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee had a specific trial of the requested seat elevator and is able to use it safely. Therefore, the reviewer found that the requested seat elevator is not medically necessary. The reviewer also found that since the seat elevator is not medically necessary, neither is the electronic connector.

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the power seat elevator and electronic connector.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power 
options and accessories (E0953, E0973, E0978, E1008, E1012, E1028, E2300,, E2311, E2313, E2331, E2361, 
E2377, E2620, K0861). 
 
You asked the Plan to pre-approve the group 3 power wheelchair with multiple power options and accessories. 
You say that this wheelchair is medically necessary. The Plan denied your request. The Plan says  standard 
group 3 power wheelchair would meet the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power 
options is covered when coverage criteria for a group 3 power wheelchair is met, and the beneficiary meets 
coverage criteria for a power tilt and recline seating system and the system is being used on the wheelchair, or 
the beneficiary uses a ventilator which is mounted on the wheelchair. 
 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 group 3 power wheelchair with 
multiple power options and accessories. Our reviewer says that the requested wheelchair is not medically 
necessary. Our physician reviewer found the enrollee has no history of skin breakdown. He also does not have 
spasticity or a clinical history of lower extremity edema. Criteria for power tilt and recline are not met, and the 
enrollee does not use a wheelchair-mounted ventilator. Since coverage criteria for the base wheelchair is not 
met, the accessories are also non-covered. 
 
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 group 3 power wheelchair with multiple power options and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair 
with multiple power options and accessories (E0953, E0973, E0978, E1008, E1012, E1028, E2300,, E2311, 
E2313, E2331, E2361, E2377, E2620, K0861).