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

We decided that the Plan does not have to pay for continued SNF care provided on July 7 to August 5, 2021.
You asked the Plan to pay for SNF care. You say that the requested SNF care was a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 pay for SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found that there is no documentation that the
enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled
professional nurse were not required to safely and effectively provide medically necessary and reasonable
treatment from July 7 through August 5, 2021. The enrollee did not require skilled therapy services, i.e., the
specialized skill, knowledge and judgment of a qualified therapist were not required to safely and effectively
provide medically necessary and reasonable treatment from July 7 through August 5, 2021. As a practical
matter, the enrollee did not require the services on an inpatient basis only in a skilled nursing facility
setting. Services in the nursing facility appear custodial in this case from July 7 through August 5, 2021.
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 pay for continued SNF care provided on July 7 to August 5, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromonitoring services (95885, 95908, 95927, 95937,
and 95955) provided on September 11, 2020.
You asked the Plan to pay for codes 95885, 95908, 95927, 95937, and 95955. You say that the medical records
support the services billed. The Plan denied your request. The Plan says the medical 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 code 95885 is Needle electromyography, each extremity, with
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study;
limited (List separately in addition to code for primary procedure). The definition of code 95908 is Nerve
conduction studies; 3-4 studies. The definition of code 95927 is 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.
The definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each
nerve, any 1 method. The definition of code 95955 is Electroencephalogram (EEG) during nonintracranial
surgery (eg, carotid surgery).
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 codes 95885, 95908, 95927, 95937, and 95955. Our reviewer
says that the medical records do not support the services billed. Our reviewer found for code 95885; this
procedure would be performed with nerve conduction studies per CPT description. Nerve conduction studies
are not documented; therefore, this procedure would not be covered. For code 95908, the technical report does
not include nerve conduction studies to include measurements of amplitude, latency, and conduction velocity,
therefore this procedure cannot be verified as performed. For code 95927, the technical report does not include
documentation of somatosensory evoked potentials (SSEP) study trunk or head. For code 95937, the technical
report does not include documentation of neuromuscular junction testing. Unable to cite report as this
procedure is not documented, and therefore would not be covered. Stimulation of Ulnar nerve at Erbs point,
per documentation is included with SSEP of Ulnar nerve. For code 95955, there is a more appropriate code to
report for EEG during non-intercranial procedures. Code 95955 is incorrect code to report for "real time"
monitoring. Any additional testing during procedure would be included in the correct HCPCS 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 codes 95885, 95908, 95927, 95937, and 95955 have not been met. Therefore,
we decided that the Plan does not have to pay for the neuromonitoring services (95885, 95908, 95927, 95937,
and 95955) provided on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive procedure provided on August 16,
2021 and August 30, 2021.
You asked the Plan to pay for the unspecified preventive procedure. You say that you had to visit the dentist
several times due to pain and do not agree with the denial. The Plan denied your request. The Plan says the
service is not a covered benefit.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
unspecified preventive procedure provided on August 16, 2021 and August 30,2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on July 16, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing 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 pay for these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee had an elevated prostate
specific antigen (PSA) of 9.6 and had three prostate biopsies. His fourth biopsy on July 10, 2021 was also
benign. The ConfirmMDx test was ordered less than one month later on August 5, 2021. There were no
documented persistent or elevated risk factors such as an increasing PSA or DRE findings at that time and no
consideration for a repeat biopsy. The criteria for coverage are not met and the testing was therefore not
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 pay for the ConfirmMDx testing rendered on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a panoramic radiographic
image (D0330), and a periapical radiographic image (D0220) provided by a participating provider on August
17, 2021.
You asked the Plan to pay for a limited oral evaluation, a panoramic radiographic image, and a periapical
radiographic image. You say that you would like the Plan to pay for the remaining balance. The Plan denied
your request. The Plan says D0140, D0330, and D0220 are not covered benefits.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited
oral evaluation (D0140), a panoramic radiographic image (D0330), and a periapical radiographic image
(D0220) provided by a participating provider on August 17, 2021.
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 you are currently on a trach, high flow to
trach at 60 liters and that cannot be done in a lower level of care. You state you could have to be intubated
again. The Plan denied your request. The Plan says your records received do not indicate all of the above. The
Plan states your request is not medically necessary because your records show you are not likely to benefit and
improve with the long-term acute care hospital. The Plan states LTACHs do not provide clinical advantage
over a non-LTACH.
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 documentation provided indicating medical necessity for LTACH
services. You are receiving appropriate care at the present acute care hospital. You do not require services at
the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan.
The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis
and condition 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: 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 stay is medically necessary. The Plan
denied your request. The Plan says the enrollee's records do not show that the ongoing care they need can only
be given in a hospital setting, or that they will require an LTACH for twenty-five (25) or more days. The Plan
states the enrollee is recovering from an acute illness. The Plan states they will need continued care, including
supplemental oxygen, intravenous antibiotics, nutrition management, and rehabilitation. The Plan states the
enrollee can safely receive this care in another setting, such as a skilled nursing facility (SNF) or at home with
home health services when they are ready to leave the acute care hospital.
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 appears to be improving and should only require short-term additional
acute care services that can be safely administered at the current facility. The enrollee does not require services
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the
enrollee requires that are not already available and covered at the current facility. Transfer to LTACH is not
supported or medically necessary due to it not being clinically advantageous.
Transfer to a lower level of care may be considered when treatment has completed.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
September 2, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the enrollee on September 2,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroplasty.
You asked the Plan to pre-approve knee arthroplasty. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 knee arthroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture is 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 knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve knee arthroplasty.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 9, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine rendered on May 6, 2021.
You asked the Plan to pay for these services. You say that you should have been warned that the vaccine would
not be covered. The Plan denied your request. The Plan says the services are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The
Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to these services.
Therefore, we decided that the Plan does not have to pay for the tetanus vaccine rendered on May 6, 2021.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from September 28, 2020, to October
2, 2020, and billed with DRG (diagnosis related group) 871.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your
request. The Plan says the sepsis diagnosis 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 DRG 871, septicemia or severe sepsis without
mechanical ventilation greater than 96 hours with major complication or comorbidities. 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 inpatient care. Our reviewer says that the billed DRG is not
supported. Our physician reviewer found the records document that the enrollee hemodynamically stable and
was described as forgetful at times. His neurological exam was non-focal. He was evaluated and admitted with
a diagnosis gastrointestinal bleed complicated by liver shock with coagulopathy. There was no clinical or
laboratory evidence of sepsis.
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 care provided from September 28, 2020, to October 2, 2020, and billed with DRG (diagnosis
related group) 871.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for implantation of a sacral nerve stimulator (64561) provided
on June 4, 2021.
You asked the Plan to pay for implantation of a sacral nerve stimulator. You say that the services at issue were
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not
been because the services at issue are experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for implantation of a sacral nerve stimulator.
Our reviewer says that the services at issue are not considered medically reasonable and necessary in this case.
Our physician reviewer found that the enrollee has unspecified urinary incontinence. Information regarding
prior treatments, voiding/incontinence diary, incontinence history, or urodynamics was not provided.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of implantation of a sacral nerve stimulator have not been met. Therefore, we
decided that the Plan does not have to pay for implantation of a sacral nerve stimulator (64561) provided on
June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete maxillary denture (D5110), and a complete
mandibular denture (D5120) provided by an opt out provider on May 19, 2021.
You asked the Plan to pay for a complete maxillary and mandibular denture. You say that you believe that you
were misinformed. The Plan denied your request. The Plan says the rendering dentist has opted out of
Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. The rendering dentist has opted out from October 15, 2015, to
October 15, 2021. Therefore, we decided that the Plan does not have to pay for a complete maxillary denture
(D5110), and a complete mandibular denture (D5120) provided by an opt out provider on May 19,2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cosentyx Sensoready pen.
You asked the Plan to pre-approve Cosentyx Sensoready pen. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cosentyx Sensoready pen.
Benefits for Cosentyx Sensoready pen may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.