Persius/hicric huggingface dataset:
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 these services are medically necessary. 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical problems are stable. The enrollee does not require treatment by multiple therapies. 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 the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental implant. 
 
You asked the Plan to pre-approve a dental implant. You say that the requested service is medically necessary. 
The Plan denied your request. The Plan says dental work is not a covered benefit under Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a 
dental implant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on September 26, 2022, billed 
with procedure code 93229. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
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 93229 is External mobile cardiovascular telemetry with 
electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of 
accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events 
transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and 
patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that in this case, report does not include 
documentation of connection and patient instruction, as well as, physician order for service provided, and 
therefore 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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on September 26, 2022, billed with procedure 
code 93229.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99222 billed for date of service January 19, 2023, and 
code 99232 billed for date of service January 20, 2023. 
 
You asked the Plan to pay for codes 99222 and 99232. You say that medical records have been provided to 
support payment. The Plan denied your request. The Plan says code 99222 billed for date of service January 19, 
2023, is not supported by the medical record. The medical records submitted don't support a moderate level of 
medical decision making or total time required of the code billed. Code 99232 billed for date of service January 
20, 2023, is also not supported by the medical record. The medical records submitted don't support a moderate 
level of medical decision making or total time required of the code 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 99222 is Initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 55 minutes must be met or exceeded. The definition of code 99232 is Subsequent 
hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires 
a medically appropriate history and/or examination and moderate level of medical decision making. When 
using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. 
  
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 codes 99222 and 99232. Our reviewer says that codes 99222 
and 99232 are not supported by the medical record. Our reviewer found the enrollee is a 79-year-old male with 
a history of osteoarthritis who underwent a total knee replacement.  He also had hyponatremia. For code 99222, 
the documentation supports an appropriate exam, but not an appropriate history or medical decision making of 
moderate level on January 19, 2023. For code 99232, the documentation supports an appropriate exam, but not 
an appropriate history or medical decision making of moderate level on January 20, 2023. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 99222 and 99232 have not been met. Therefore, we decided that the Plan 
does not have to pay for code 99222 billed for date of service January 19, 2023, and code 99232 billed for date 
of service January 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunofluorescence stain (88350, 10 units) provided on 
March 10, 2023. 
 
You asked the Plan to pay for 88350. You say that you have performed 10 units of this service. The Plan 
denied your request. The Plan says per the coding manual, only 1 unit of 88350 is allowed for an 
immunofluorescent antibody stain per specimen even if it contains multiple separately interpretable antibodies. 
 
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 88350 (10 units) is immunofluorescence, per specimen; 
each additional single antibody stain procedure (list separately in addition to primary procedure). 
 
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 88350. Our reviewer says that this code does not meet 
criteria for payment. Our reviewer found the provider reported 10 units of this code; however, the lab report 
does not support additional units. Per coding guidelines, the unit of service for immunofluorescent antibody 
studies is each antibody staining procedure per specimen. If a single antibody staining procedure for one or 
more antibodies is performed on multiple blocks from a surgical specimen, multiple slides from a cytologic 
specimen, or multiple slides from a hematologic specimen, only one unit of service shall be reported for each 
separate specimen. Providers/suppliers shall not report more than one unit of service for an immunofluorescent 
antibody stain per specimen for an immunofluorescent antibody staining procedure even if it contains multiple 
separately interpretable antibodies. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 88350 have not been met. Therefore, we decided that the Plan does not have to 
pay for immunofluorescence stain (88350, 10 units) provided on March 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on September 2, 2022. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the records do not support that 22 or more drug classes were tested. 
 
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 tests, definitive; qualitative or quantitative, 
all sources, includes specimen validity testing, per day; 22 or more drug class(es), includes metabolites if 
performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not support 
that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug 
testing provided on September 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 27, 2023, to 
April 25, 2023. 
 You asked the Plan to pay for the home health services. You say that the NOA was submitted with the final 
claim. 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 March 27, 2023. The NOA was not received by the Plan until June 9, 2023. 
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 
March 27, 2023, to April 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs to continue physical and 
occupational therapy to treat severe dehydration, rhabdomyolysis, transaminitis, and lactic acidosis.  The Plan 
denied your request. The Plan says a SNF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service March 28, 2023. 
 
You asked the Plan to pay for code 99285. You say that the code billed was supported by the medical records. 
The Plan denied your request. The Plan says code 99285 is not supported by the medical record. The enrollee 
had a low risk of morbidity from additional diagnostic testing or treatment. As a result, code 99285 was down-
coded, and code 99284 was paid instead. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
 1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 code 99285 Our reviewer says that code 
99285 is not supported by the medical records. Our reviewer found the enrollee was a 62-year-old female with 
a history of benign positional vertigo who presented to the emergency room with a chief complaint of 
dizziness. She was discharged after receiving intramuscular treatment for her symptoms with plans for follow-
up with her primary care provider. The documentation provided is consistent with 99284 (i.e., detailed rather 
than comprehensive). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve surgical extraction of teeth #22, 24, 25, and 26 (D7210). 
 
You asked the Plan to pre-approve surgical extraction of teeth #22, 24, 25, and 26. You say that the services are 
necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers surgical 
extraction of teeth when the services are medically necessary and reasonable. 
 
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 surgical extraction of teeth #22, 24, 25, 
and 26. Our reviewer says that the services are medically necessary. Our physician reviewer found a review of 
the documentation indicates that teeth #'s 22-26 require extraction due to root canal failure and fractures. The 
coverage of the crowns and root canals of these teeth makes them more prone to fracture upon removal. 
Surgical removal is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of surgical extraction of teeth #22, 24, 25, and 26 have been met. Therefore, we 
decided that the Plan has to pre-approve surgical extraction of teeth #22, 24, 25, and 26 (D7210).  
 
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: Favorable

 
We decided that the Plan has to pre-approve a portable oxygen concentrator (D1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the medical records support 
the need for the portable oxygen concentrator. The Plan denied your request. The Plan says that there was no 
documentation of medical need for a portable oxygen concentrator.  
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patient's skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account.  
 
For patients who do not exhibit hypoxemia according to the above criteria, oxygen may be coverable when 
medically reasonable and necessary for patients who do not have a non-covered indication.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the portable oxygen concentrator.  Our 
reviewer says that the portable oxygen concentrator is medically necessary. Our physician reviewer found the 
enrollee has COPD and has desaturation with exertion and meets criteria for oxygen therapy. 
 
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 portable oxygen concentrator have been met.  Therefore, we decided that the 
Plan has to pre-approve a portable oxygen concentrator (D1392).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services without transport received on March 14, 
2023. 
 
You asked the Plan to pay for the ambulance services without transport. You say that the enrollee should not be 
responsible for payment as the services are a covered cost. The Plan denied your request. The Plan says if there 
is no transport than services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 14, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services without transport received on 
March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on September 8, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup services (D2950) provided on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99204 billed for date of service March 29, 2023. 
 
You asked the Plan to pay for code 99204. You say that medical records have been provided to support 
payment. The Plan denied your request. The Plan says code 99204 is not supported by the medical records. The 
records don't support a moderate level of medical decision making or total time required of the code 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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient which requires a medically appropriate history and/or examination 
and moderate medical decision making. Typical face-to-face time: 45-59 minutes. 
 
 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 code 99204. Our reviewer says that code 99204 is not 
supported by the medical record. Our reviewer found the enrollee is a 69-year-old man who presented for a 
second opinion regarding left hand numbness and a prior diagnosis of carpal tunnel syndrome. In this case, the 
documentation supports an appropriate exam and history, but not medical decision making of moderate level or 
that 45 minutes or more were spent. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99204 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99204 billed for date of service March 29, 2023.