Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
rendered on November 4, 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 criteria is not met for payment of CPT 99285 because there was no significant/immediate threat 
to life or physiological function. 
 
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 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: 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) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
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 while the examination is 
comprehensive, the history is not comprehensive. There is no evidence of medical decision making of high 
complexity. The records do not support the presenting problems were of high severity, posing an immediate 
significant threat to life and function. 
 
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 emergency department services (procedure code 99285) rendered on November 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
10, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services rendered on August 4, 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 provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
The rendering provider is not eligible to bill Medicare. The plan did not pre-approve the services. We found no 
exception that would require the plan to pay for these services. 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 emergency room services rendered on August 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services (G2067) provided on December 19, 
2022. 
 
You asked the Plan to pay for opioid treatment services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. 
 
We looked at the file and Medicare rules. This claim was billed by an individual provider and not an approved 
treatment facility. Based on this information, we decided that Medicare rules for coverage of opioid treatment 
services have not been met. Therefore, we decided that the Plan does not have to pay for opioid treatment 
services (G2067) provided on December 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ankle-foot orthosis (AFO) (L1960). 
 
You asked the Plan to pre-approve the AFO. You say that the AFO is medically necessary. The Plan denied 
your request. The Plan says the AFO is not 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 the AFO. Our physician reviewer found 
the criteria for bilateral L1960 Ankle-foot orthosis (AFO), posterior solid ankle, plastic, custom fabricated have 
not been met per LCD L33686. The documentation does not support that the brace will be used during 
ambulation as the enrollee is noted to be wheelchair bound. The documentation is not clear that the enrollee is 
unable to use a prefabricated AFO. 
 
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 AFO have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the ankle-foot orthosis (AFO) (L1960).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429) provided on September 27, 
2022. 
 
You asked the Plan to pay for the ambulance services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as 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 find that CPT code A0429 is not supported in the medical record. Specifically, this code was billed with an 
invalid modifier (RW). Based on this information, we decided that Medicare rules for coverage of the 
ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
services (A0429) provided on September 27, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for imaging services provided on October 21, 2022, billed with procedure 
code 77080. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that the diagnosis is not consistent with the 
procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the denial rationale offered by the Plan is not supported. The Plan 
states that the services are not covered when considered preventative. We find that the services are reasonable 
and necessary. As such, we find that the denial of payment on this basis is not substantiated. Therefore, we 
decided that the Plan has to pay for imaging services provided on October 21, 2022, billed with procedure code 
77080.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture therapy to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve acupuncture therapy to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture therapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit (99336) provided on July 19, 2022, by 
an out-of-network (OON) provider. 
 You asked the Plan to pay for the evaluation and management service. You say that the service should be paid. 
The Plan denied your request. The Plan says the ordering provider and rendering provider are out-of-network. 
The Plan also says that prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit (99336) provided on July 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) provided on November 23, 2022. 
 
You asked the Plan to pay for the drug testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed service. 
 
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 G0482 is Drug Testing, Definitive, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records provided do not 
show at least 15 drug classes were tested. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
drug testing (G0482) provided on November 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted procedure, spine (22899) provided October 28, 
2022. 
 
You asked the Plan to pay for the surgical procedure. You say that the enrollee has a platelet rich plasma 
injection with fluoroscopic guidance and there is not CPT code when used in the cervical area. Please review 
the operative report and approve for payment. The Plan denied your request. The Plan says this procedure does 
not meet the criteria for an ambulatory surgery center. 
 
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 22899 is unlisted procedure, spine. 
 
We find that CPT code 22899 is not supported in the medical record. Specifically, CPT code 22899 is not listed 
as coverable in an ambulatory surgical center. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay 
for unlisted procedure, spine (22899) provided October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit (99215) provided on February 9, 
2022. 
 
You asked the Plan to pay for a physician office visit. You say that the service at issue has been billed 
correctly. 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 June 10, 2022. 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 a physician office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for a physician office visit (99215) provided on 
February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (procedure code 99291 and 99292) 
rendered on April 8, 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) 99291 and 99292 remain 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 the denied codes is: 
 
CPT 99291: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes  
CPT 99292: 
 
Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 
minutes (List separately in addition to code for primary service) 
 
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 this procedure is reported by time 
spent providing critical care services, which in this case is not documented in the report. Therefore, the denied 
codes 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care services (procedure code 99291 and 99292) rendered on April 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 28, 2022, to 
February 26, 2022. 
 You asked the Plan to pay for the home health services. You say that when you spoke to the Plan, it was 
unclear if the Plan was going to require an NOA instead of a Request for Anticipated Payment (RAP). You said 
that you submitted a RAP timely, so this should be paid. 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 January 28, 2022. The NOA was not received by the Plan until November 
15, 2022. 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 January 28, 2022, to February 26, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) additional physical therapy visits (97164 x 5). 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says 5 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 the therapy services. 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 the enrollee has previously been treated with outpatient therapies and 
should be independent with a home exercise program. There is no documentation of a recent injury or decline 
in function. The additional therapy services are not an 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 the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve five (5) additional physical therapy visits (97164 x 5).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Tempus xF testing provided on November 7, 2022. 
 
You asked the Plan to pay for Tempus xF testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of Tempus xF testing have not been met. 
Therefore, we decided that the Plan does not have to pay for Tempus xF testing provided on November 7, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on December 
28, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
December 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 for date of service October 6, 2022. 
 
You asked the Plan to pay for procedure code 99223. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 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 procedure code 99223. Our reviewer says that the 
documentation does not support the code billed. Our reviewer found the enrollee was admitted to the hospital. 
The enrollee's symptoms resolved in the emergency department and the enrollee remained medically stable. 
The documentation does not support decision making of high complexity. Therefore, code 99223 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 procedure code 99223 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99223 for date of service October 6, 2022.
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 December 3, 
2022 to December 26, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. 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 December 3, 2022 to December 26, 2022.