Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 21 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you are showing progress but still need 
additional physical therapy sessions to be able to recoup completely. You say that you have no other health 
issues that are preventing you from functioning except your neck.  The Plan denied your request. The Plan says  
21 additional physical therapy visits is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that you have previously been treated with outpatient 
therapies and should be independent with a home exercise program. You have no recent injury or a decline in 
function. The additional therapy services are not appropriate duration and frequency for treatment of your 
medical condition and therefore are 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 21 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99222) provided on December 2, 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 99222 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 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 use of code 99222 is 
not supported by the records provided. Our reviewer found that the provided records do not document a chief 
complaint, an extended history of present illness, a review of all additional body systems and a complete past, 
family and social history. The records do not document a general multisystem examination or a complete 
examination of a single organ system. The records document 2 out of 3 of multiple diagnoses or management 
options, a moderate amount and complexity of data reviewed and moderate risk of complication. The records 
do not document 50 minutes were spent at the bedside and on the patient's hospital floor or unit. 
 
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 (99222) provided on December 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023 to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023 to January 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the service provided on December 6, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation. 
 
We looked at the file and Medicare rules. The record shows that the claim was billed with primary diagnosis 
code F05. This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. 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 service provided on December 6, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records support the need for IRF 
admission.  The Plan denied your request. The Plan says the enrollee does not meet the medical necessity 
criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 30, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this testing is not 
covered for screening. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on September 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a commode (E0163). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of confinement that would preclude using a toilet within the 
residence. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the enrollee has the capacity to go to outpatient therapy and get into the shower. The enrollee is not 
room-confined, and has access to regular toilet facilities. 
 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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a commode (E0163).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99212-25 billed for date of service June 20, 2022. 
 
You asked the Plan to pay for code 99212-25. You say that code 99212 was performed for a different reason 
than the procedure. The Plan denied your request. The Plan says code 99212-25 is not supported. This code is 
included in the global day period for code 36478. The submitted documentation doesn't support a significant, 
separately identifiable evaluation and management service to support the use of the 25 modifier. 
 
The Plan follows Medicare rules. Medicare rules say that  the 25 modifier is used to identified an evaluation 
and management service (E/M) that is separately identifiable by the same physician on the same day of a 
procedure.   
 
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 99212-25. Our reviewer says that the 
use of the 25 modifier to allow for separate payment of code 99212 is not supported by the medical record. Our physician reviewer found the procedure report does not include sufficient documentation to confirm that this 
evaluation and management service was separate from the procedure with a global period. Therefore, the 
evaluation and management service is related to the procedure performed. 
 
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 99212-25 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99212-25 billed for date of service June 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation and inpatient 
admission. 
 
You asked the Plan to pre-approve computer-assisted surgical navigation and inpatient admission. 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 computer-assisted surgical navigation 
and inpatient admission. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found computer assist is not needed for shoulder 
replacement surgery. Also, the surgery can be safely performed with a 48 hour observational stay.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted surgical navigation and inpatient admission have not been 
met. Therefore, we decided that the Plan does not have to pre-approve computer-assisted surgical navigation 
and inpatient admission.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on August 22, 2021. 
 
You asked the Plan to pay for an electrocardiogram. You say that the claims were submitted to the wrong 
department, and you should not be billed for the services. The Plan denied your request. The Plan says there is 
no documentation of medical history or current medical condition that requires an electrocardiogram. The 
provider is out of network and has not submitted any clinical documentation or prior authorization that supports 
the medical need for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
   
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an electrocardiogram have been met. 
There are no medical records within the casefile. Without the requested clinical information, we are unable to 
determine if the requested services are medically necessary. Therefore, we decided that the Plan does not have 
to pay for an electrocardiogram (93010) provided on August 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
August 31, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documents do not support this level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 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 plan was to wean 
vasopressors and diuresis and monitor vitals. There was no documented formal plan for advanced or 
interventional treatments at that time. Although the medical decision-making was of at least moderate 
complexity due to shock, the exam was detailed and focused, and the history was not comprehensive. 
 
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 initial hospital care (procedure code 99223) rendered on August 31, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Select MDx testing (0339U) provided October 18, 2022. 
 
You asked the Plan to pay for the Select MDx testing . You say that this testing was medically necessary. The 
Plan denied your request. The Plan says that coverage criteria are not met for this testing. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the Plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The enrollee was referred for the Select MDx testing by a contract provider. The file does not show that the 
Plan provided notice that the Select MDx testing would not be covered. Under Medicare rules, this means the 
Select MDx testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the 
Select MDx testing (0339U) provided October 18, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 
 
You asked the Plan to pay for the billed code. You say that the code was billed after the report was received.  
The Plan denied your request. The Plan says an appropriate primary procedure code was not 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.  
 
We looked at the file and the rules. The case file does not include documentation that the code was billed on 
the same date as an appropriate primary procedure code. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 88341
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023, to January 28, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S5124 billed for date of service January 10, 
2023 to January 27, 2023. 
 
You asked the Plan to pay for procedure code S5124. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S5124 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S5124 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S5124 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S5124 billed for date of service January 10, 2023 to January 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is a medical necessity. The Plan denied your 
request. The Plan says you do not require an intensive level of therapy requiring physician oversight. 
 
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 you do not require the intensity of services provided at an 
IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Your care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says 24 additional 
physical therapy visits are not medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has previously been treated with outpatient 
therapies and should be independent with a home exercise program. The enrollee has no recent injury or a 
decline in function. The additional therapy services are not appropriate duration and frequency for treatment of 
the enrollees medical condition and therefore are 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 24 additional physical therapy visits.