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

 
We decided that the Plan does not have to pay for outpatient therapy services provided from August 2, 2021, to 
September 26, 2021. 
 
You asked the Plan to pay for the outpatient therapy services. You say that you have provided medical records 
to show the necessity of these services. The Plan denied your request. The Plan says outpatient therapies 
beyond 12 visits require prior authorization.  There was no authorization request submitted for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan can require prior authorization for 
services.  The Evidence of Coverage says that prior authorization rules apply to outpatient therapies.  The 
Plan's prior authorization rules say that any outpatient therapies beyond the first 12 visits require prior 
authorization.  You did not request prior authorization for the outpatient therapies beyond the first 12 visits.  
You have provided no explanation as to why you did not request this required prior authorization.  
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient therapy services have not been met. Therefore, we decided that the Plan does not 
have to pay for outpatient therapy services provided from August 2, 2021, to September 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that bone marrow aspirate is medically 
necessary in this instance. The Plan denied your request. The Plan says the clinical value and effectiveness of 
bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed 
literature. 
 
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 bone marrow aspirate. Our reviewer 
says that bone marrow aspirate is not medically necessary. Our physician reviewer found in this case, the 
record indicates that the enrollee is undergoing spinal fusion surgery.  There is insufficient literature to 
demonstrate the safety and efficacy, as defined by Medicare rules, of the requested procedure for the enrollee's 
specific clinical condition.  The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you require rehab for mental and physical well-
being. The Plan denied your request. The Plan says you do not have daily skilled needs and you can be safely 
managed in your current acute care setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the records, you are unable to 
participate in physical therapy and unable to verbalize.  You do not require skilled nursing or skilled therapy 
services on a daily basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested admission to a SNF does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found no required skilled nursing services are 
identified. The specialized skill, knowledge and judgment of a skilled professional nurse are not required to 
safely and effectively provide medically necessary and reasonable treatment. The enrollee appears to be 
functioning close to her baseline. The documentation does not support that it is medically reasonable and 
necessary to provide these skilled nursing or skilled therapy services (or a combination of these services) on a 
"daily basis" on an inpatient basis, in a skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 16, 
2021. 
 
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) code 83789-59 remains 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. Medicare rules say that specimen validity testing 
is not covered separately.  
 
In this case, the CPT Code Manual definition of code 83789 is "Mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen." 
 We find that CPT code 83789 is not supported in the medical record. Specifically, the services at issue in this 
case are for the purpose of specimen validity testing, and should not be reported separately. 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 drug testing services provided to the enrollee on August 16, 
2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment of $110 for an in-network outpatient hospital diagnostic 
hearing screening. We decided that the Plan does not have to waive the copayment for $100 for an in-network 
outpatient hospital diagnostic hearing test.  
 
You asked the Plan to waive the copayment for $110 for an in-network outpatient hospital diagnostic hearing 
screening. You say that the copayment should be waived. The Plan says that the copayment charged is correct. 
 We decided that the Plan has to reduce the copayment of $110 for an in-network outpatient hospital 
diagnostic hearing test.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $100 copayment for other outpatient diagnostic tests. In-
network outpatient diagnostic hearing test falls within the outpatient diagnostic tests and therapeutic services 
and supplies benefit category. 
 
The Plan says you must pay a $110 copayment for in-network outpatient diagnostic hearing test. Based on the 
Plan contract, however, you cannot be asked to pay more than a $100 copayment for an in-network outpatient 
diagnostic hearing test. Therefore, we decided that the Plan has to reduce the copayment for an in-network 
outpatient hospital diagnostic hearing test from $110 to $100.  
 
We also decided that the Plan does not have to waive the copayment for $100 for an in-network 
outpatient hospital diagnostic hearing test. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for other outpatient diagnostic tests. Therefore, we decided that the Plan does not have to waive the 
copayment for $100 for an in-network outpatient hospital diagnostic hearing test. 
 
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 pay for the continuous intraoperative neurophysiology monitoring 
(95941) provided on February 23, 2021. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring (95941). You say that 
the services were ordered by the patient's in-network surgeon as a surgical requirement and were provided in an 
in-network facility. You say that the provider has privileges to render this type of service as third-party 
neuromonitoring personnel and payment should be authorized. The Plan denied your request. The Plan says 
CPT code 95940 was paid, and CPT code 95941 is not payable by Medicare. 
 
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 95941 is continuous intraoperative neurophysiology 
monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while 
in the operating room, per hour (List separately in addition to code for primary procedure). 
 
We find that CPT code 95941 is not supported in the medical record. Specifically, CPT code 95941 has a status 
indicator of I. This means that CPT code 95941 is not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of the continuous intraoperative neurophysiology monitoring 
(95941) have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
intraoperative neurophysiology monitoring (95941) provided on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
(95941) provided on July 12, 2021. 
 
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring (95941). You say that 
the services were ordered by the patient's in-network surgeon as a surgical requirement and were provided in an 
in-network facility. You say that the provider has privileges to render this type of service as third-party 
neuromonitoring personnel and payment should be authorized. The Plan denied your request. The Plan says 
payment for CPT codes 95940 and 95955 was issued. The Plan also says that CPT code 95941 is not payable 
by Medicare. 
 
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 95941 is continuous intraoperative neurophysiology 
monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while 
in the operating room, per hour (List separately in addition to code for primary procedure). 
 
We find that CPT code 95941 is not supported in the medical record. Specifically, CPT code 95941 has a status 
indicator of I. This means that CPT code 95941 is not valid for Medicare purposes. Based on this information, 
we decided that Medicare rules for coverage of the continuous intraoperative neurophysiology monitoring 
(95941) have not been met. Therefore, we decided that the Plan does not have to pay for the continuous 
intraoperative neurophysiology monitoring (95941) provided on July 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on October 26, 
2021, and billed under codes 74430, 93005 and 51741. 
 
You asked the Plan to pay for these services. You say that these codes should be covered by the Plan. The Plan 
denied your request. The Plan says this claim was paid under OPPS (Outpatient Prospective Payment System). 
Payments for codes 74430, 93005 and 51741 are packaged into payment for other services. Therefore, there is 
no separate Ambulatory Payment Classification (APC) payment for codes 74430, 93005 and 51741. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case it has been confirmed that these codes 
are bundled within codes already paid on this claim and cannot be billed separately. Therefore, we decided that 
the Plan does not have to pay for medical services provided to the enrollee on October 26, 2021, and billed 
under codes 74430, 93005 and 51741.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone length studies (77073) provided on November 9, 
2021. 
 
You asked the Plan to pay for the bone length studies (77073). You say that it is expected for the Plan to follow 
Medicare payment processing guidelines. You say that the referenced claim is underpaid, and you expect the 
remaining balance to be reimbursed. The Plan denied your request. The Plan says the correct payment was 
made at 100% Medicare Ambulatory Payment Classifications (APC). The Plan also says that payment for CPT 
code 77073 is packaged into APC rates. 
 
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 77073 is bone length studies (orthoroentgenogram, 
scanogram). 
 
We find that CPT code 77073 is not supported in the medical record. Specifically, payment for CPT code 
77073 is considered packaged and not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the bone length studies (77073) have not been met. Therefore, we decided that the Plan 
does not have to pay for the bone length studies (77073) provided on November 9, 2021.
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 you would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet 
criteria for coverage of the requested IRF 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 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 are medically stable and do not need physical medicine and rehabilitation 
physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. At the current functional level, you do not need intensive 
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach to daily therapy 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided on 
April 17, 2021. 
 
You asked the Plan to pay for the CGM supplies. 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 billed supplies. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the medical records submitted do not discuss the 
supplies at issue. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor 
(CGM) supplies provided on April 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electromyography (procedure code 95870) provided to 
the enrollee on February 10, 2021. 
 
You asked the Plan to pay for the electromyography procedure. 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 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 electromyography procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the erollee had routine lumbar spine surgery. EMG monitoring during the 
surgery was not medically needed. The procedure may have been safely performed without neuromonitoring of 
the lumbar spine nerves. 
 
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 electromyography procedure have not been met. Therefore, we decided that 
the Plan does not have to pay for the electromyography (procedure code 95870) provided to the enrollee on 
February 10, 2021.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 
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: 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says a lower level of care is more appropriate for you. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. There is not a reasonable expectation that you 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.