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

We decided that the Plan does not have to pay for neuromuscular junction testing (95937), an 
electroencephalogram (95955), nerve conduction studies (95908) and needle electromyography (95885) 
provided on February 3, 2020. 
 
You asked the Plan to pay for the neuromuscular junction testing, electroencephalogram, nerve conduction 
studies and needle electromyography. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation did not support the services 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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
The CPT Code Manual definition of code 95955 is electroencephalogram. 
 
The CPT Code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. 
 
The CPT Code Manual definition of code 95885 is needle electromyography, each extremity, with related 
paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited 
(List separately in addition to code for 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 the neuromuscular junction testing, electroencephalogram, 
nerve conduction studies and needle electromyography. Our reviewer says that CPT codes 95937, 95955, 
95908 and 95885 do not meet criteria for billing or reimbursement consideration. Our reviewer found CPT 
95937 was not documented in the technical report.  Provider reported CPT 95937 for Train of Four testing.  
Train-of-four monitoring is bundled with the intraoperative neuromonitoring of electromyography (EMG) or 
motor evoked potentials (MEP) and, therefore, is not separately reportable. The documentation does not 
include enough detail to confirm CPT 95955.  Documentation supports a baseline EEG, and there, this code 
cannot be verified. The technical report does not include nerve conduction studies.  CPT 95908 would not be 
reported for pedicle screw or direct root stimulations. The documentation does not include needle 
electromyography, each extremity, therefore was unable to verify 95885 as performed.  
 
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 neuromuscular junction testing, electroencephalogram, nerve conduction 
studies and needle electromyography have not been met. Therefore, we decided that the Plan does not have to 
pay for neuromuscular junction testing (95937), an electroencephalogram (95955), nerve conduction studies 
(95908) and needle electromyography (95885) provided on February 3, 2020.
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 the records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. 
The Plan says that the enrollee can safely receive the services needed in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 
was admitted for osteomyelitis, acute encephalopathy and acute renal insufficiency. The enrollee's medical 
problems are stable. There are no identified problems that need inpatient medical management. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The 
medical record supports a need for physical and occupational therapy but it does not support a need for an 
intensive rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for closed treatment of vertebral body fracture (23310) provided 
on January 2, 2020. 
 
You asked the Plan to pay for the closed treatment of vertebral body fracture. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the service 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 22310 is closed treatment of vertebral body fracture(s), 
without manipulation, requiring and including casting or bracing. 
 
We asked our review coder er 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 closed treatment of vertebral body 
fracture. Our reviewer says that CPT code 22310 doe not meet criteria for billing or reimbursement 
consideration. Our reviewer found the documentation does not include description of treatment given, as well 
as casting or bracing.  Therefore this service cannot be verified as performed. 
 
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 closed treatment of vertebral body fracture have not been met. Therefore, 
we decided that the Plan does not have to pay for closed treatment of vertebral body fracture (23310) provided 
on January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve the inpatient psychiatric care. You say that the inpatient psychiatric care 
being requested is medically necessary. The Plan denied your request. The Plan says the records do not show 
that care is needed at an inpatient level and cannot be performed in an outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was 
admitted to the acute inpatient psychiatric hospitalization on October 25, 2020, with Adjustment Disorder with 
Mixed Disturbance/Emotional Conduct. Based upon review the records provided it was not expected this 
enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any 
dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors or any acute 
threats of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have 
any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors.  
 
It did not appear that active treatment was taking place beyond the date in question. It did not appear that the 
services for the dates in question were reasonably expected or medically necessary to improve the patient's 
condition or for the purpose of diagnosis. The enrollee could have been treated in a lesser restrictive 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 the inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
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 the records provided support the need for admission 
to an IRF. The Plan denied your request. The Plan says admission to an IRF is not medically necessary at this 
time. The Plan says that the records indicate that the enrollee has not had a decline to his prior level of function. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 patient was 
admitted for non surgical management of knee fracture after a fall. The enrollee's medical problems are stable. 
There are no identified problems that need inpatient medical management. There are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports 
a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation 
therapy program. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve iron dextran injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical documentation does not show a trial of oral iron supplementation. 
 
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 injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee was offered either oral iron or IV iron, and the enrollee chose the IV iron. In this case, the 
iron stores were not low enough to justify IV iron as she had not tried and failed oral iron which is less invasive 
and longer lasting. Therefore, this request for IV iron will be considered 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve iron dextran injection for the enrollee.
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 the records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the clinical information does not show that the guidelines for 
coverage of IRF care have been met. The Plan says that the enrollee's needs can be safely met in a lower level 
of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 
was admitted for a hip fracture after a fall. He received a blood transfusion and was treated for pneumonia. The 
enrollee's medical problems are stable. There are no identified problems that need inpatient medical 
management. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. The medical record supports a need for physical and occupational therapy, but it does not 
support a need for an intensive rehabilitation therapy program.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve care with an out of network (OON) tertiary level of care 
provider. 
 
You asked the Plan to pre-approve care with an OON tertiary level of care provider. You say that you would 
like the enrollee to have a second opinion from the requested tertiary facility before surgery. The Plan denied 
your request. The Plan says the records provided did not demonstrate why the requested OON tertiary level of 
care is medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollee's needs. The enrollee's contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 care with an OON tertiary level of care 
provider. Our reviewer says that the criteria for coverage OON have not been met. Our physician reviewer 
found the enrollee has a clinical stage I breast cancer that is estrogen positive and HER2 negative.  A 
mastectomy with sentinel lymph node dissection is planned followed by chemotherapy with paclitaxel and 
trastuzumab with or without pertuzumab depending on final pathology. This is the standard of care for this 
breast cancer. There is nothing unique about this case that would make it medically necessary to seek an out-of-
network tertiary care provider. Adequate care is available in network. OON care is not 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 care with an OON tertiary level of care provider have not been met. Therefore, 
we decided that the Plan does not have to pre-approve care with an out of network (OON) tertiary level of care 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pulsed radiofrequency (RF) of the facet joints. 
 
You asked the Plan to pre-approve the pulsed RF of the facet joints. You say that the requested services are 
minimally invasive and medically necessary to avoid surgery. You say that this will avoid surgery and the risks 
associated with surgery. You say that the requested services will also alleviate sciatic nerve pain. You say that 
surgery would cost the plan a lot more money. You say that the enrollee is in a lot of pain. The Plan denied 
your request. The Plan says the clinical information does not describe positive facet joint examination results 
between the levels that the injections are being requested for. The Plan says that the requested injection 
services are not indicated at this time. The Plan says that the clinical information does not describe two 
successful medial branch blocks, and this also shows that the requested procedure is not indicated at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that non-thermal RF modalities for facet joint 
denervation are not covered. 
 
We looked at the file and Medicare rules. Therefore, we decided that the Plan does not have to pre-approve 
pulsed radiofrequency (RF) of the facet joints.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation to a level 1 trauma center provided on March 
4, 2020. 
 
You asked the Plan to pay for the transportation. You say that you would like reconsideration because 
transportation to the level 1 trauma center was medically necessary based on your past cardiac experiences. The 
Plan denied your request. The Plan says transportation to the more distant level 1 trauma center was not 
medically necessary. 
 
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 pay for the transportation. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided records did not show that you exhibited an acute condition which required the 
services only available at a trauma 1 center. Also, the notes did not show that you could not have been treated 
appropriately at another closer location. 
 
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 transportation have not been met. Therefore, we decided that the Plan does 
not have to pay for transportation to a level 1 trauma center provided on March 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have 
not been met. The Plan says that the services needed could be provided in another setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the current acute care hospital with acute respiratory 
failure due to COVID-19 pneumonia. He was treated with convalescent plasma, oxygen, remdesivir. He was 
tested positive with COVID-19 again two weeks later while in the hospital and was again treated with 
convalescent plasma. He is weaning down on oxygen requirements and is being treated with diuresis. The 
records show that the enrollee is improving and that he requires additional short-term acute care for additional 
stabilization and treatment, but that this should take less than 25 days, and could safely be completed at the 
current facility. The enrollee does not require services at the LTACH that are not already available at the 
current setting. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current setting. Transfer to a lower level of care may be considered when treatment has 
completed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.