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

We decided that the Plan does not have to pay for the electromyography services (95865 and 95870) provided on June 8, 2021.
You asked the Plan to pay for the electromyography services. You say that based on the medical records, you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the diagnosis submitted is not among those covered for this service.
The Plan must follow Medicare rules. Medicare rules say that electromyography services will not be covered when the diagnosis billed is classified as a disorder of the thyroid gland. We looked at the file and Medicare rules. In this case, the billed diagnosis is listed as E04.1 which is defined as Nontoxic single thyroid nodule. This is not among the covered diagnoses for the electromyography services. Based on this information, we decided that Medicare rules for coverage of the electromyography services have not been met. Therefore, we decided that the Plan does not have to pay for the electromyography services (95865 and 95870) provided on June 8, 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 the enrollee is not safe to return home and needs inpatient rehabilitation services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the necessary services in an alternate setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 for the enrollee's
condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 on review of the available records the enrollee with periprosthetic knee fracture,
status post revision is medically stable and does not meet Medicare coverage criteria for an IRF admission.
With her current medical stability, and no other medical complexity, there is no need for 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, she does not
require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with
multidisciplinary approach to daily therapy. Her rehab needs can be addressed just as well in a skilled nursing
facility. IRF admission is not medically necessary based on lack of medical complexity. The documentation
does not support the necessity for admission to an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to be held harmless for the anesthesia services (00410) provided on July 15, 2021.
You asked the Plan to be held harmless for the anesthesia services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that this claim has been billed with an inappropriate place of service.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the anesthesia services by a contract provider. The file does not show that the Plan provided notice that the anesthesia services would not be covered. Under Medicare rules, this means the anesthesia services is considered approved by the Plan. Therefore, we decided that the Plan has to be held harmless for the anesthesia services (00410) provided on July 15, 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
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 services as you cannot walk anymore
and need the level of care provided in a hospital. The Plan denied your request. The Plan says the criteria for
admission to an IRF are not met. Your nursing, medical management and rehabilitation needs can be provided
in an alternate setting, such as a skilled nursing facility.
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. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the
expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 hospital services. Our
reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The
record indicates that the enrollee is scheduled for a laminotomy. The record does not document that the treating
physician has a reasonable expectation of a length of stay spanning 2 or more midnights. Our physician
reviewer found that the enrollee's condition does not meet criteria for inpatient 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 hospital services have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for
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 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 95887:
Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure) CPT 95907: Nerve conduction studies; 1-2 studies CPT 95957: Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) 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 CPT 95886 and 95887 are not covered, as there is no documentation that nerve conduction studies were performed. Per the description of the code, these codes must be performed with nerve conduction studies. In terms of CPT 95907, the procedure report does not document nerve conduction studies, and therefore cannot be verified. Nerve conduction studies measure amplitude and latency velocity. This is not documented in report. In terms of CPT 95957, the procedure report does not include documentation of sensors applied to head to measure and record the brain's electrical activity, per NCCI Policy Manual, therefore, this procedure cannot be confirmed as performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from May 18, 2021,
through June 15, 2021.
You asked the Plan to pay for psychotherapy services. You say that you would like these claims reprocessed
and approved for payment. The Plan denied your request. The Plan says there is no documentation of a
consultation with the attending physician.
The Plan must follow Medicare rules. Medicare rules say that CPs are required to document a consultation with
the primary or attending physician or the attempt to make such a consultation.
We looked at the file and Medicare rules. There is no documentation in this record supporting consultation or
attempt at consultation was performed. Based on this information, we decided that Medicare rules for coverage
of psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for
psychotherapy services provided from May 18, 2021, through June 15, 2021.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve home health skilled nursing visits for the enrollee.
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan denied your request. The Plan says that the notes do not show an open ulcer.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health services. Our reviewer says that the requested visits are medically reasonable and necessary. Our physician reviewer found that based on the medical records provided, there is documentation that the enrollee is homebound, and has a chronic open wound (stage III venous stasis ulcer) on the right lateral calf area which requires skilled nursing 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 home health services have been met. Therefore, we decided that the Plan has to pre-approve home health skilled nursing visits for the enrollee.
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 acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that this admission is medically necessary. The Plan
denied your request. The Plan says an admission to an inpatient rehabilitation facility 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 enrollee's medical problems are stable and there is no documentation of a need for
an intensive rehabilitation program.
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 the enrollee's needs cannot be met at a lower level of
care. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of
an IRF admission does not meet the requirements for approval.
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 the enrollee's 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 the enrollee will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for tissue transfer procedures (14301 and 14302) provided on April 19, 2021.
You asked the Plan to pay for tissue transfers. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not supported by the medical records.
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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 square centimeters to 60.0 square centimeters. The CPT Code Manual definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30 square centimeters, or part thereof (List separately in addition to code for primary procedure).
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for tissue transfers. Our reviewer says that these codes do not meet the criteria for payment. Our reviewer found the operative report does not include enough information to confirm flat sections of healthy skin and other tissues are transferred or transplanted to the area adjacent to a skin defect, and measurement to confirm this procedure. The operative report describes a complex closure. Therefore, code 14301 is not supported. Code 14302 is an "add on" code and would not be covered if the primary code is denied. The operative report does not document defect size to confirm this code. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tissue transfers have not been met. Therefore, we decided that the Plan does not have to pay for tissue transfer procedures (14301 and 14302) provided on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve infectious agent detection by nucleic acid testing.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next-generation sequencing (NGS) is covered
when specific criteria are met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show you have elevated
prostate specific antigen (PSA). You do not have a diagnosis of recurrent, relapsed, refractory, metastatic, or
advanced stage III or IV cancer. There is no documentation that the requested testing would impact the
management and outcome of your condition. The records do not support that the NGS testing is reasonable or
medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve infectious agent detection by nucleic acid testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (procedure code 44140) provided to the
enrollee on February 5, 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 the denied code 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.
In this case, the CPT Code Manual definition of code 44140 is "Colectomy, partial; with anastomosis."
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 operative report does not include
documentation of anastomosis; therefore CPT 44140 cannot be confirmed as performed. Per the operative
report "A small colotomy was created in the transverse colon (in the portion planned for resection) and air
evacuated. The colotomy was closed with 3-0 vicryl suture." Therefore, an appropriate modifier should be
appended.
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 surgical services (procedure code 44140) provided to the enrollee on February 5, 2021.