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

 
We decided that the Plan does not have to pay for a blood smear interpretation billed with code 85060 for date 
of service February 4, 2022. 
 
You asked the Plan to pay for code 85060. You say that the billed date of service reflects the pathologist's date 
of interpretation and not the date of collections. The Plan denied your request. The Plan says the service in 
dispute was billed with an inappropriate place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that code 85060 has a physician interpretation code 
of 8 and can only be paid if the physician interprets an abnormal smear for hospital inpatient.  
 
We looked at the file and Medicare rules. The records show that code 85060 was billed with a Place of Service 
code of 22, representing outpatient services. The documentation provided does not indicate that the enrollee 
was inpatient for the date of service being billed. Payment cannot be made for code 85060 when furnished 
outside of an inpatient hospital.  
 
 
 
  
Based on this information, we decided that Medicare rules for coverage of code 85060 have not been met. 
Therefore, we decided that the Plan does not have to pay for a blood smear interpretation billed with code 
85060 for date of service February 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray coded 71045 provided on October 16, 2021. 
 
You asked the Plan to pay for an x-ray. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 71045 is radiologic examination, chest; single view. 
 
We find that CPT code 71045 is not supported in the medical record. Specifically, the documentation shows 
that a claim was submitted and previously processed/paid by the Plan for the same service for the same date of 
service. The documentation does not support additional services were completed. Based on this information, 
we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan 
does not have to pay for an x-ray coded 71045 provided on October 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care provided to the enrollee from January 26, 2022, 
to January 28, 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 records do 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 the denied codes is: 
 
CPT 99222: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are 
spent at the bedside and on the patient's hospital floor or unit 
 
 CPT 99233: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new 
problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the enrollee had peripheral artery 
disease and foot ulcers, and underwent vascular surgery evaluation. The review has determined that the records 
did not support the denied codes in this case. 
 
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 hospital care provided to the enrollee from January 26, 2022, to January 28, 2022.
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 need IRF care to return home safely. The Plan 
denied your request. The Plan says criteria for admission to the IRF setting have not been met. Your ongoing 
skilled therapy and nursing needs can be provided at 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 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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented, calibrated pneumatic compression device 
(PCD) coded as E0652. 
 
You asked the Plan to pre-approve the E0652 PCD. You say that the requested E0652 PCD is the only device 
that will be able to treat the enrollees condition. The Plan denied your request. The Plan says LCD criteria for 
this device have not been met.  
 
The Plan follows Medicare rules. Medicare rules say that PCDs coded E0652 are covered only for lymphedema 
extending onto the trunk/chest/abdomen that has failed treatment for four weeks with an E0650 or E0651 PCD. 
 
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 E0652 PCD. Our reviewer says that 
the requested E0652 PCD is not considered medically reasonable and necessary. Our physician reviewer found 
the vascular surgery office note, dated 02/11/2022, states the member has a history of lymphedema; "edema is 
well-controlled in the right lower extremity; it is moderate in the left lower extremity". There is no 
documentation of edema of the trunk, abdomen, or chest. Office note, dated 01/26/2022, states within physical 
examination: "edema is well-controlled in the bilateral lower extremities...edema is mild". There is no 
documentation of edema of the trunk, abdomen, or chest at this visit. Office note, dated 01/05/2022, states 
moderate edema of the bilateral lower extremities. Without swelling extending onto the trunk or abdomen, 
criteria for the E0652 PCD are not met. 
 
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 E0652 PCD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a segmented, calibrated pneumatic compression device (PCD) coded as E0652.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that you no longer require inpatient 
psychiatric treatment or 24 hour professional supervision. 
 
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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you will improve in a reasonable period of time as you are not showing any dangerousness to self 
or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute 
threats of safety. It does 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 as you do not have any suicidal or homicidal 
thoughts, auditory or visual hallucinations or abnormal behaviors. Our physician reviewer found that your 
condition does not meet criteria for coverage of inpatient psychiatric hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Powered Pressure-Reducing Air Mattress (E0277). 
 
You asked the Plan to pre-approve a Powered Pressure-Reducing Air Mattress. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the item is medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is covered if the beneficiary 
meets at least one of the three Criteria listed 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 a Powered Pressure-Reducing Air 
Mattress. Our reviewer says that the item is not medically necessary. Our physician reviewer found the records 
do not show there is evidence of multiple stage two or greater ulcers on the trunk and pelvis. Also, treatment 
has been initiated, but there is no evidence  or description in the notes that you have failed current treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Powered Pressure-Reducing Air Mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Powered Pressure-Reducing Air Mattress (E0277).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2025, V2781) provided on January 21, 
2022. You asked the Plan to pay for eyeglasses. You say that you were told you could use any provider for this 
benefit. The Plan denied your request. The Plan says you have another claim on file for eyeglasses which were 
purchased on January 24, 2022. This claim was received by the Plan first and was processed and paid. Your 
benefit covers a maximum of $100 toward the purchase and fitting of eyeglasses and pair of lenses or contact 
lenses once per calendar year. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $100 once per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that you also purchased eyeglasses on January 24, 
2022, and these services were covered by the Plan at that time. Your benefit may only be used once per 
calendar year. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not 
been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2025, V2781) 
provided on January 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the short latency somatosensory evoked potential study 
(95938), central motor evoked potential study (95939), needle electromyography (95870), and continuous 
intraoperative neurophysiology monitoring, from outside the operating room (G0435) provided on November 
30, 2021. 
 
You asked the Plan to pay for the diagnostic services. You say that the services were ordered by an in network 
surgeon and provided in an in network facility. You also say that the services were medically necessary. The 
Plan denied your request. The Plan says the services do not meet the criteria for coverage. 
 
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 95938 is the services do not meet the criteria for coverage. The CPT Code Manual definition of code 95939 is central motor evoked potential study (transcranial 
motor stimulation); in upper and lower limbs. The CPT Code Manual definition of code 95870 is needle 
electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), 
other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters. The CPT Code Manual definition 
of code G0435 is continuous intraoperative neurophysiology monitoring, from outside the operating room 
(remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition 
to 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 diagnostic services. Our reviewer says that the diagnostic 
services were not medically necessary. Our reviewer found the provided documentation does not support the 
billing of the procedure codes on this claim. 
 
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 diagnostic services have not been met. Specifically, the file does not support 
that the procedure codes at issue in this case were provided. Therefore, we decided that the Plan does not have 
to pay for the short latency somatosensory evoked potential study (95938), central motor evoked potential 
study (95939), needle electromyography (95870), and continuous intraoperative neurophysiology monitoring, 
from outside the operating room (G0435) provided on November 30, 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely in other settings. 
 
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. 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 was admitted for stroke. The enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation 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. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of an intermittent pneumatic compression device 
(PCD). 
 
You asked the Plan to pre-approve the requested PCD. You say that you were ordered to use this device as you 
are at risk for blood clots without it. You feel that this is medically necessary. The Plan denied your request. 
The Plan says Medicare does not cover equipment for preventive purposes. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for prevention of venous thromboembolism.  
 
 
  
Therefore, we decided that the Plan does not have to pre-approve use of an intermittent pneumatic compression 
device (PCD).
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 LTACH specializes in the specific 
care that the enrollee needs. The Plan denied your request. The Plan says the enrollee's subacute care can be 
provided at the current facility. 
 
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 that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. The health plan has approved ongoing care in the current acute care facility. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
  
 
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.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (99221) provided on October 18, 2021, and 
subsequent hospital care (99232) provided on October 19, 2021. 
 
You asked the Plan to pay for hospital services. You say that that these services were rendered by different 
providers and were billed appropriately. The Plan denied your request. The Plan says that these services have 
already been paid for a higher level of service under claims for another provider within the same group and 
specialty. Therefore, the services at issue are included in the payment for these other services which have 
already been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that both Initial Hospital Care (CPT codes 99221 - 
99223) and Subsequent Hospital Care codes are "per diem" services and may be reported only once per day by 
the same physician or physicians of the same specialty from the same group practice. 
 
We find that CPT codes 99221 and 99232 are supported in the medical record. While the record shows that 
other initial or subsequent hospital care services were billed for these dates by another provider at the same 
facility, the National Provider Identifier (NPI) registry shows that these two providers have different specialties 
and taxonomy codes. Based on this information, we decided that Medicare rules for coverage of hospital 
services have been met. Therefore, we decided that the Plan has to pay for initial hospital care (99221) 
provided on October 18, 2021, and subsequent hospital care (99232) provided on October 19, 2021.  
 
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.