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

 
We decided that the Plan does not have to pay for practitioner services provided on December 27, 2022, to 
December 29, 2022, billed with procedure codes 99224 and 99217. 
 
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 codes. 
 
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 codes 99224 and 99217 is subsequent observation care, per 
day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: 
Problem focused interval history; Problem focused examination; Medical decision making that is 
straightforward or of low 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 stable, recovering, or improving. Typically, 15 
minutes are spent at the bedside and on the patient's hospital floor or unit, and observation care discharge day 
management (This code is to be utilized to report all services provided to a patient on discharge from outpatient 
hospital "observation status" if the discharge is on other than the initial date of "observation status." To report 
services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, 
use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-
99236 as appropriate.]) 
 
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 codes. Our reviewer found that in this case, documentation does not 
support observation, as status was not included in the medical record. 
 
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 December 27, 2022, to December 29, 2022, 
billed with procedure codes 99224 and 99217.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 87491-59 and 87640-59 provided July 25, 2023. 
 
You asked the Plan to pay for the laboratory services . You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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, we have confirmed that code 87640 is a column II code to column I code 87641; however, 87640 
was billed with a modifier.  
 
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 laboratory services. Our reviewer found the 
documentation submitted was reviewed and does not meet criteria. The laboratory report does not include 
documentation of Chlamydia trachomatis test was performed or physician order for test. Our coder was unable 
to cite report, as this documentation was not found in medical record. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 87491-59 and 87640-59 provided July 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on August 11, 2023, billed 
with procedure codes 95937-26 and G0453-59. 
 
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 codes 
 
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, we have confirmed that code G0453 is a column II code to column I code 95955; however, G0453 
was billed with a modifier.  
 
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 codes. Our reviewer found that code 95937 is not supported. The 
record states that it was reported for train of four testing, this is not a separately reportable procedure. Code 
G0453-59 is not supported as separately identifiable. The intraoperative neuromonitoring is included in 95955 
in this case and is not a separate and distinct service. 
 
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 August 11, 2023, billed with procedure 
codes 95937-26 and G0453-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sedation. 
 
You asked the Plan to pre-approve sedation. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of sedation have not been met. Specifically, anesthesia is considered not reasonable and necessary for 
facet joint interventions. Therefore, we decided that the Plan does not have to pre-approve the sedation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on August 01, 2023, to August 08, 
2023. 
 
You asked the Plan to pay for the home visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit provided 
on August 01, 2023, to August 08, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  an electronic connection between wheelchair controller 
and one power seating system motor (E2310). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you are appealing on 
the grounds that Medicare has reviewed and approved and found it medically necessary and covered. You also 
say that the Plan should follow Medicare's decision. The Plan denied your request. The Plan says  although a 
single power feature is requested for this wheelchair, there is not a medical need to control this power option 
through the joystick. 
 
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 durable medical equipment (DME). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found according to Medicare a power mobility device is medically necessary 
if a beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more 
mobility-related activities of daily living. The mobility limitation cannot be sufficiently and safely resolved by 
the use of a fitted cane or walker, or the beneficiary does not have sufficient upper extremity function to self-
propel an optimally-configured manual wheelchair. Additionally, if any power operated vehicle (POV) or 
power wheelchair (PWC) is only for use outside the home, it is denied as noncovered. The enrollee must also 
have the mental and physical capabilities to safely operate the power wheelchair and the home provides 
adequate access between rooms, maneuvering space, and surfaces for the operation of the PWC. An 
expandable controller is an electronic system that is capable of accommodating one or more additional features 
and can operate 3 or more powered seating options. The requested electrical accessories are not medically 
necessary as the enrollee does have use of the upper extremity and can operate and control the power options 
using the switches that are included in the basic wheelchair. There is not a medical need for the upgraded 
electronics. 
 
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 durable medical equipment (DME) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve  an electronic connection between wheelchair controller and 
one power seating system motor (E2310).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95913 and 95886 billed for date of service 
July 24, 2023.  
 
You asked the Plan to pay for procedure codes 95913 and 95886. You say that the services should be paid. The 
Plan denied your request. The Plan says payment for code 95913 is bundled into payment for code 95867. 
Code 95886 is considered an add-on code to primary code 95913. 
 
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, we have confirmed that code 95913 
is a column two code to column one code 95867 with a modifier indicator of 0. The column two code is 
therefore not payable. We have confirmed that code 95886 is an add-on code to primary code 95913. 
Therefore, codes 95886 and 95913 are not payable. 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 codes 95913 and 
95886 billed for date of service July 24, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing, of 15-21 drug classes (G0482) provided 
April 24, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that you would like the medical records to be 
reviewed and the claim to be reprocessed and paid in full. The Plan denied your request. The Plan says that 
under Medicare rules, the number of definitive urine drug classes requested are not medically necessary. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has been taking Baclofen, Hydrocodone, Alprazolam, Seratine and Lyrica for pain. 
There was an inconsistent result on the screening test. Because this was a new finding of inconsistent drug use, 
definitive drug testing was medically reasonable and 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 laboratory service have been met. Therefore, we decided that the Plan has to 
pay for the definitive drug testing, of 15-21 drug classes (G0482) provided April 24, 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 wheelchair (E1130) purchased on June 13, 2023. 
 
You asked the Plan to pay for the wheelchair. You say that the item should be covered. The Plan denied your 
request. The Plan says this item was purchased through a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the wheelchair (E1130) purchased on 
June 13, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Image Guided Radiation Therapy (IGRT), 25 fractions (77387). 
 
You asked the Plan to pre-approve IGRT. You say that the enrollee needs the additional treatment as soon as 
possible. The Plan denied your request. The Plan says that using IGRT during part of the enrollee's radiation 
therapy is not necessary. 
 
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 IGRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found for radiation in the definitive setting, IGRT could be considered medically necessary when 
escalating the dose (as is done with curative treatment), particularly when using very relatively higher dose per 
fraction (not applicable to this case), or when critical normal tissues abutting the target necessitate daily image 
guidance to allow minimal planning margins to spare the normal tissue. In this case, the daily computed 
tomography (CT) scan can verify alignment of the bladder and rectum on a day-to-day basis and is consistent 
with accepted standards of care during the boost phase of treatment, and when justified with a plausible 
rationale, during the pelvic radiotherapy phase of treatment. As IGRT allows more accurate treatment delivery, 
which can be challenging when targeting the bladder (even when using large fields to treat the pelvis including 
bladder and nodes), it provides a plausible benefit. The decision is favorable as the reviewer believes that IGRT 
can be considered an accepted standard 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 IGRT have been met. Therefore, we decided that the Plan has to pre-approve 
Image Guided Radiation Therapy (IGRT), 25 fractions (77387).  
 
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 the urinary tract infection (UTI) Pro Panel provided June 13, 
2023, billed with codes 87481, 87500, 87653, 87798. 
 
You asked the Plan to pay for the laboratory testing. You say that please review the medical documentation to 
support the diagnosis coding and medical necessity of the denied line items. The Plan denied your request. The 
Plan says this claim is a duplicate of a previously paid claim and was correctly denied.  

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 14, 2023. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the laboratory testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the urinary tract infection (UTI) Pro Panel provided June 13, 
2023, billed with codes 87481, 87500, 87653, 87798.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 16, 2022, 
to December 23, 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 A41.9 is 
supported in the documentation, therefore the claim should be paid at the DRG originally billed. The Plan 
denied your request. The Plan says A41.9 is not supported in the documentation. 
 
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 A41.9, defined as sepsis, 
unspecified organism. 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 A41.9 is not supported in the 
documentation. Our physician reviewer found the enrollee presented with abdominal pain. They were found to 
have appendicitis, which was complicated by perforation, bacteremia and a post-operative ileus. The enrollee 
appears to have been clinically stable with no evidence of sepsis (for example, hypotension, hypoperfusion, 
organ failure).  
 
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 16, 2022, to December 23, 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 LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that given the enrollee's complex 
hospitalization combined with the ongoing need for the surgical drain management and the need for continued 
monitoring of multiple antifungals being administered, an LTACH is the optimal facility to provide ongoing 
care. The Plan denied your request. The Plan says admission to an LTACH is not medically necessary.  
 
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 appropriate care in the current acute care setting as 
provided by the Plan. The 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair and bathtub wall rail. 
 
You asked the Plan to pre-approve a shower chair and bathtub wall rail. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says these items are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that bath/shower chairs  and grab bars are not covered 
because they are not primarily medical in nature.  
 
While a shower chair and bathtub wall rail may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair 
and bathtub wall rail.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance transportation provided in the United Mexican 
States on August 1, 2023. 
 
You asked the Plan to pay for air ambulance service. You say that the enrollee should be paid the full amount 
for services. The Plan denied your request. The Plan says transportation back to the United States from another 
country is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States and its territories are not covered except in limited specified circumstances. The enrollees 
contract with the Plan offers worldwide coverage that goes beyond Medicares rules. For that reason, the Plans 
rules apply to this case. Transportation back to the United States from another country is not covered by the 
Plans worldwide coverage benefits. 
 
We looked at the file, the Plans rules, and Medicare rules. Based on this information, we decided that the 
Plans rules for coverage of air ambulance service have not been met. Therefore, we decided that the Plan does 
not have to pay for air ambulance transportation provided in the United Mexican States on August 1, 2023.