Persius/hicric huggingface dataset:
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 the requested admission to a SNF 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee had 
barrier cream to her peri area after each incontinence episode and prn. She used oxygen via nasal cannula. The 
enrollee does not require skilled nursing or therapy services on a daily basis. She does not meet severity of 
illness or intensity of service criteria for 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) (CPT code J9271). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says this medication is not FDA approved or supported by Medicare approved 
compendia for the condition(s). 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the medication can only be used as a basis of approval if there are no other reasonable alternatives. The 
enrollee can have any single agent including taxanes, gemzar, or nalvebine. This medication is not 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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda (pembrolizumab) (CPT code J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve. 
 
You asked the Plan to pre-approve thermal destruction of intraosseous basivertebral nerve. You say that 
thermal destruction of intraosseous basivertebral nerve is medically necessary. The Plan denied your request. 
The Plan says the requested thermal destruction of intraosseous basivertebral nerve is 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 pre-approve thermal destruction of intraosseous 
basivertebral nerve. Our reviewer says that thermal destruction of intraosseous basivertebral nerve is not 
considered medically reasonable and necessary. Our physician reviewer found that this is an experimental/ 
investigational procedure. Therefore, the request is deemed not medically reasonable or 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 thermal destruction of intraosseous basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve thermal destruction of intraosseous 
basivertebral nerve.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653, 87651, 87798, and 
87641 billed for date of service March 15, 2021. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87653, 87651, 87798, and 87641. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87481, 
87640, 87653, 87651, 87798, and 87641 is bundled into payment for code 87801. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  
 
In this case, we have confirmed that codes 87481, 87640, 87653, 87651, 87798, and 87641 are column II codes 
to column I code 87801. While these codes were billed with the -59 modifier, the medical records provided do 
not show that the services billed with the -59 modifier is a distinct procedural service. 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 87481, 87640, 87653, 87651, 87798, and 87641 billed for date of service March 15, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 7, 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 you 
disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the 
billing of primary diagnosis code A41.9. 
 
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 primary diagnosis code A41.9. 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 the submitted records do not support the billing of primary diagnosis code A41.9. Our 
physician reviewer found the enrollee presented to the hospital with cholangitis. The laboratory findings did 
not document a creatinine equal to or greater than 1.2 mg/dl. During the admission patient was noted to have 
oxygen desaturation requiring two liters of oxygen; however, the enrollee had fluid overload with pleural 
effusions. There were no arterial blood gas studies completed during the hospital stay. Although the diagnosis 
of sepsis was documented, sufficient supporting documentation was not found within the medical record.  
 
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 May 7, 2021, at the Diagnosis Related Group (DRG) originally 
billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for inpatient hospital services provided on 
January 20, 2021, to January 24, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay an additional amount for the inpatient hospital services at the DRG originally billed. 
You say that the records support the billing of principal diagnosis code A41.9. The Plan denied your request. 
The Plan says the billing of principal diagnosis code, A41.9, Sepsis, unspecified organism, is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9 defined as sepsis, 
unspecified organism. We asked our physician reviewer to carefully review the case file and apply the relevant 
Medicare rules to determine if the Plan was correct in denying the request to pay an additional amount for the 
inpatient hospital services at the DRG originally billed. Our reviewer says that the billing of the principal 
diagnosis code, A41.9, is not supported. Our physician reviewer found the provided documentation shows that 
the facility has indicated that there was a Sequential Organ Failure Assessment (SOFA) score of 3; however, 
the clinical evidence did not support this finding. The reviewer found that the provided documentation 
indicates the SOFA score was 0. Therefore, the diagnosis of sepsis was not valid according to Sepsis-3 criteria. 
Therefore, the reviewer found that the provided documentation did not support the billing of principal 
diagnosis code, A41.9, Sepsis, unspecified organism.  
 
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 
an additional amount for inpatient hospital services provided on January 20, 2021, to January 24, 2021, at the 
Diagnosis Related Group (DRG) originally billed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided on August 4, 2021. 
  You asked the Plan to pay for occupational therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the code is not 
appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that therapy services billed as services incident to a 
physician/non-physician practitioners service must meet all incident requirements. Medicare rules also say that 
the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) 
service, because they do not meet the qualifications of a therapist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy services have not been met. Specifically, the records do not indicate if the 
rendering provider was an occupational therapist or an OTA. A nurse practitioner is not able to bill for the 
services of an OTA because the nurse practitioner is not a therapist. There is no evidence that the nurse 
practitioner was on the premises to be able to bill for occupational therapy services. Additionally, the record 
does not include the rendering providers credentials, so we are unable to verify the billed services. Therefore, 
we decided that the Plan does not have to pay for occupational therapy services provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided on May 19, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does 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. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the date the specimen was 
collected (May 5, 2022) does not match the date of service billed. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81455) provided on May 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a FoundationOne gene panel (81455) provided on March 1, 
2022. 
 
You asked the Plan to pay for a FoundationOne gene panel. You say that this was medically necessary. The 
Plan denied your request. The Plan says this is not a payable code. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under the 
code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and 
will be denied automatically as not medically necessary.  
 
We looked at the file and Medicare rules. The testing at issue was reported with 81455 and is not considered 
medically necessary. Based on this information, we decided that Medicare rules for coverage of a 
FoundationOne gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a 
FoundationOne gene panel (81455) provided on March 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97530) provided on July 7, 2021. 
 
You asked the Plan to pay for procedure code 97530. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
Medicare rules say that therapy services provided and billed incident to the services of a physician/NPP also 
must meet all incident-to requirements. 
 We find that CPT code 97530 is not supported in the record. Specifically, the record shows that this claim was 
billed by a nurse practitioner and the services were rendered by an occupational therapist. A nurse practitioner 
cannot bill for the services of an occupational therapist. Therefore, we decided that the Plan does not have to 
pay for the therapy services (97530) provided on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 31, 2022. 
 
You asked the Plan to pay for physician's services. You say that your radiologists are staffed at the facility and 
it is the responsibility of the facility to obtain the proper authorization. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are 
not urgent or emergent, nor were they approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services} provided on January 4, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 laboratory services} provided on January 4, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative neurophysiology monitoring (procedure codes 
95886, 95907, 95937) provided to the enrollee on April 20, 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 services are not supported in the medical records submitted. 
 
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 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
 CPT 95907: 
 
Nerve conduction studies; 1-2 studies 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
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 CPT 95886 and 95907 were not 
the appropriate codes to be billed, as a nerve conduction study was not done. The enrollee did not undergo a 
formal nerve conduction study, as defined by the CPT description and the American Clinical Neurophysiology 
Society (ACNS) standards. Rather, the services performed were stimulation of the pedicle screws during 
surgery. Stimutlation of pedicle screws is considered to be triggered electromyography (EMG) and is 
considered part of the CPT code for EMG services. In terms of CPT 95937, the enrollee underwent train of four 
testing. However, the submitted code reflects neuromuscular junction testing neuromuscular junction testing, 
which was not done for diagnostic purposes in this case. As such, this CPT code was also not supported by the 
records. 
 
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 intraoperative neurophysiology monitoring (procedure codes 95886, 95907, 95937) provided to 
the enrollee on April 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has complex medical needs 
that require ongoing acute care. The Plan denied your request. The Plan says admission to the LTACH was 
denied as not meeting criteria, is not medically necessary, and continued acute hospital stay was offered, until 
the enrollee could discharge to a lower level of care. 
 
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 is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a varicose vein treatment procedure (37765, 36471). 
 
You asked the Plan to pre-approve the procedure. You say that the service is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that treatments of the tributary veins will be considered 
medically necessary if saphenous reflux is not present or already successfully eliminated. 
 
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 procedure. Our reviewer says that 
this procedure is not medically necessary. Our physician reviewer found there is documentation of saphenous 
reflux for which treatment is intended but has not yet been performed. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a varicose vein treatment procedure (37765, 36471).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided November 2, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 0037U is not supported in the medical record. Specifically, the date the specimen was 
collected (August 11, 2021) does not match the billed date of service. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan 
does not have to pay for genetic testing (0037U) provided November 2, 2021.