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

 
We decided that the Plan does not have to pay for procedure codes 95822 representing an 
electroencephalogram and 95927 representing a short-latency somatosensory evoked potential study provided 
on May 4, 2022. 
 
You asked the Plan to pay for electroencephalogram and short-latency somatosensory evoked potential study. 
You say that the services were medically necessary. The Plan denied your request. The Plan says the records 
submitted do not support procedure codes 95822 and 95927. 
 
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 definitions of code 95822 and 95927 are electroencephalogram (EEG); 
recording in coma or sleep only and short-latency somatosensory evoked potential study, stimulation of any/all 
peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 
 
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 an electroencephalogram (EEG); recording in coma or sleep 
only and Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin 
sites, recording from the central nervous system; in the trunk or head. Our reviewer says that these codes are 
included in more specific codes for intraoperative neuromonitoring and should not be reported separately in 
this case. Our reviewer found that the records submitted do not support procedure codes 95822 and 95927. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of electroencephalogram and short-latency somatosensory evoked potential study. 
 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95822 
representing an electroencephalogram and 95927 representing a short-latency somatosensory evoked potential 
study provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth number 9. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says the request is not medically necessary. There are no signs that more than 
half of your tooth has damage that is from decay or injury. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the request is not medically necessary, the criteria for coverage has not been met. Our physician reviewer 
found that the documentation provided was not sufficient to determine if the coronal structure of tooth number 
9 was severely broken down to warrant a crown restoration. The radiographs provided were not of diagnostic 
quality.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) for tooth number 9.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95822 and 95927 billed for date of service 
April 21, 2022. 
 
You asked the Plan to pay for procedure codes 95822 and 95927. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says these services are not supported 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 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 codes 95822 and 95927. Our reviewer says that the use of codes 95822 and 95927 is not supported in this case. Our reviewer found the record states that the 
electroencephalogram (EEG) was performed as intraoperative neuromonitoring and the somatosensory evoked 
potentials (SSEP) was performed on the ulnar and tibial nerves. The documentation does not state that needles 
were placed in the trunk or head to evaluate these sites. There are more accurate code options to report the 
services described 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 procedure codes 95822 and 95927 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 95822 and 95927 billed for date of service April 21, 
2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 93042 representing a rhythm electrocardiogram provided on December 20, 2021.

You asked the Plan to pay for an electrocardiogram. You say that the claim should be paid as billed. The Plan denied your request. The Plan says procedure code 93042 remains unsupported.

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 93042 is rhythm electrocardiogram.

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 electrocardiogram. Our reviewer says that the documentation does not support that the services described by this code were performed. Our reviewer found the procedure report does not provide clear documentation to support the electrocardiogram billed was provided to support reporting 93042.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electrocardiogram. have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 93042 representing a rhythm electrocardiogram provided on December 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 28, 2022.

You asked the Plan to pay for procedure code 76705. You say that the enrollee had multiple exams on the date in question. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976.

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 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service September 27, 2022.

You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. The Plan denied your request. The Plan says code 83789 is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service September 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 8, 2022.

You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.

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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on October 12, 2021.

You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim.

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code.

We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on October 12, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta.

You asked the Plan to pre-approve Zilretta. You say that this injection is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Zilretta. Our reviewer says that Zilretta is medically necessary. Our physician reviewer found Zilretta is indicated as an intra-articular injection for the management of osteoarthritis pain of the knee. The enrollee had a previous injection in November, 2022. Documentation supports that Zilretta is medically reasonable and necessary for the patient and is safe and effective for the patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve Zilretta.

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: 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 enrollee has already failed at a lower level of care. You believe this is the best option for the enrollee to receive the appropriate care and prevent readmission. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer.

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 there is no evidence that the enrollee requires services that are not currently available. The enrollee can remain at the current acute care hospital until such time no acute services are required. The enrollee can then be transferred or discharged to a lower level of care for any ongoing long term care needs.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes 87150, 87798, and 87641, billed for date of service April 5, 2022.

You asked the Plan to pay for procedure codes 87150, 87798, and 87641. The Plan denied your request. The Plan says payment for codes 87150, 87798, and 87641 is bundled.

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 87150 is a column II code to column I code 87500. We have also confirmed that codes 87798 and 87641 are column II codes to column I code 87150. This claim has not been billed with an appropriate modifier to bypass the edit. 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 87150, 87798, and 87641, billed for date of service April 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 28, 2022.

You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.

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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the electrical stimulator supplies provided on October 15, 2022.

You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that the proof of delivery did not include an order number or details to corroborate the delivery ticket submitted.

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. The Plan argues that the proof of delivery did not include an order number or details to corroborate the delivery ticket submitted. However, the documentation contains an itemized packing slip with the same tracking number as the delivery ticket which shows the items in question were delivered. As such, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the electrical stimulator supplies provided on October 15, 2022.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (0202U) provided on February 5, 2022.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that code 0202U is not covered.

We looked at the file and Medicare rules. Per LCA A56581, the billed code, 0202U, is a non-covered code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (0202U) provided on February 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorperazine.

You asked the Plan to pre-approve Prochlorperazine. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that oral anti-emetic drugs that are used as full replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prochlorperazine have not been met. Therefore, we decided that the Plan does not have to pre-approve Prochlorperazine.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99284 billed for date of service May 23, 2022.

You asked the Plan to pay for procedure code 99284. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says payment for code 99284 is bundled into payment for code 99291.

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 99284 is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99284 billed for date of service May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on September 8, 2021, to September 11, 2021, 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 these services and diagnoses were reported correctly and are supported as billed. The Plan denied your request. The Plan says the DRG submitted for these services is not supported in the medical record.

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 acidosis (E87.2). 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 this diagnosis is not supported in the medical record. Our physician reviewer found in this case, the submitted documentation did not provide clear evidence for the reason or suspected cause of acidosis, and there was no documentation of specific intervention to address or correct the acidosis. The review has determined that the documentation does not support reporting a diagnosis of acidosis (E87.2).

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 September 8, 2021, to September 11, 2021, at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 43274-22 billed for date of service June 29, 2022.

You asked the Plan to pay for procedure code 43274. You say that this service is supported as billed. The Plan denied your request. The Plan says this service is not supported in the medical record.

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 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 43274-22. Our reviewer says that the use of modifier 22 with CPT code 43274 is not supported. Our reviewer found although the endoscopic retrograde cholangiopancreatography (ERCP) with stent placement was performed, and the surgeon stated that it was a prolonged procedure, the details in the operative report do not support that the work was substantially greater than what is typically required for this procedure. Therefore, the record does not support the use of modifier 22 with code 43274 for prolonged services.

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 43274 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 43274-22 billed for date of service June 29, 2022.