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

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
January 8, 2020, through January 31, 2020. 
 You asked the Plan to pay for the SNF services as billed. You say that the SNF care as billed is supported by 
the medical documentation. The Plan denied your request. The Plan says based on the services rendered, the 
SNF services have not been billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that SNF services are 
processed under a payment system listed in the Medicare rules section. 
 
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 SNF services as billed. Our reviewer says that the 
documentation does not support payment for the SNF services as billed. Our reviewer found the patient is an 
86-year-old female who underwent surgery and a request for SNF stay was made for 1/8/20 to 1/31/20 for post-
surgical care and rehabilitation. In this case, you have billed a PDPM originally of KAGE1. The Plan has made 
the determination that the G and E are not supported in the medical documentation. Based on the 
documentation, the only intravenous solution was the lactated ringer's solution directly related to the surgery 
and was not for nutrition/hydration reasons alone and so the billing of special care high services (G) is not 
supported. Based on the documentation, the patient received protein supplementation during the first few days 
of SNF stay, however, there was no physician documentation describing the patient as having protein-calorie 
malnutrition or risk for such to support the "E" designation. The SNF care as billed is not supported by the 
medical documentation. 
 
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 SNF care as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the skilled nursing facility (SNF) services provided from January 8, 2020, through 
January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor billed for services provided 
on April 7, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed supply 
code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the continuous glucose monitor billed for services provided on 
April 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance or emergency response provided on September 8, 
2021, without transport. 
 
You asked the Plan to pay for ambulance or emergency response without transport. You say that this service 
should be covered by the Plan. The Plan denied your request. The Plan says ambulance or emergency response 
without transport is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. The ambulance company did not provide transport services on September 8, 2021. The 
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays 
for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance or 
emergency response provided on September 8, 2021, without transport.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat facet joint injections (64494, 64493). 
 
You asked the Plan to pre-approve the repeat facet joint injections. You say that the injections are 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 a second confirmatory diagnostic facet joint 
procedure is considered medically reasonable and necessary when after the first diagnostic facet joint 
procedure, there is a consistent positive response of at least 80% relief of primary (index) pain. 
 
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 repeat facet joint injections. Our 
reviewer says that the repeat injections are not medically necessary. Our physician reviewer found the records 
show the initial injection only provided 50% pain relief. 
 
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 repeat facet joint injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve repeat facet joint injections (64494, 64493).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64486-59 billed for date of service 
September 21, 2021. 
 
You asked the Plan to pay for procedure code 64486-59. You did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says you did not bill with an appropriate anatomic modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers or suppliers shall use anatomic 
modifiers (e.g., RT, LT, FA, F1-F9, TA, T1-T9, E1-E4) and report procedures with differing modifiers on 
individual claim lines when appropriate. In this case, you billed with procedure code 64486, which by 
definition is a unilateral code.  This would mean that an anatomical modifier is needed to indicate which side 
this procedure was performed on. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 64486-59 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 64486-59 billed for date of service September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. 
The requested Superion spacer is considered experimental in nature, as more research is needed to show safety 
and efficacy. The services are 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 pre-approve a Vertiflex Superion spacer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C. 
 
You asked the Plan to pre-approve Gamunex-C. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says Gamunex-C is not being prescribed for a medically-accepted 
indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Gamunex-C. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found that the patient has 
post immunization encephalitis following COVID-19 vaccine based on cerebrospinal fluid analysis and brain 
biopsy. He was treated with high dose corticosteroids without significant response. Intravenous immune 
globulin (IVIG) was recommended. He received IVIG therapy with significant clinical benefit which worsened 
after delay in repeat treatment. A request for Gamunex-C was made for autoimmune encephalitis treatment. In 
this case, this medication is not FDA approved for the patient's condition. Furthrmore, the major drug 
compendia do not provide sufficient support for using IVIG for the patient's specific condition and there is also 
insufficient clinical res each in one of the Medicare-approved medical journals to support its use for the patient's condition.  
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gamunex-C have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gamunex-C.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on March 1, 2021. 
 You asked the Plan to pay for the testing services. You say that the test offers predictive biomarker testing. The 
Plan denied your request.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The records show that the testing does not change physician 
management. Based on this information, we decided that Medicare rules for coverage of the testing services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided on 
March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on September 29, 2021. 
 You asked the Plan to pay for the testing services. You say that the testing provides actionable results. The Plan 
denied your request. The Plan says the test is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, there are no medical records from the treating provider 
to show the testing was ordered for a specific treatment strategy or medical problem. There is insufficient 
information in the record to determine if Medicare rules for coverage have been met. Therefore, we decided 
that the Plan does not have to pay for the CxBladder testing provided on September 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapist on July 23, 2020. 
  You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-
contract providers at the preferred provider rate when services are not available from preferred providers in the 
service area. You say that the in-network benefits should be honored, and the claim processed for payment. 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 services of an occupational therapist billed as 
services incident to a physician/non-physician practitioners service must meet all incident requirements.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, OT services cannot be paid incident to this provider's professional services. Therefore, 
we decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapist on July 23, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and a course of IV antibiotics. The enrollee had stable vital signs and used oxygen via nasal 
cannula. The enrollee was at a moderate to maximal assist level with functional mobility and tolerated a 
mechanical soft diet and thin liquids. The enrollee does not require skilled nursing or therapy services on a 
daily basis and 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95938) provided August 24, 2021. 
 
You asked the Plan to pay for the neuromonitoring services. You say that these 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. 
 
In this case, the CPT Code Manual definition of code 95938 is Short-latency somatosensory evoked potential 
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper 
and lower limbs. 
 
 
 We find that CPT code 95938 is not supported in the medical record. Specifically, the technical report does not 
describe the procedure billed. Based on this information, we decided that Medicare rules for coverage of the 
neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for 
neuromonitoring services (95938) provided August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee needs a ventilator since bi-level 
positive airway pressure (BiPAP) does not include auto-exhalation mode, battery backup, or mouthpiece 
ventilation and a ventilator will increase quality of life. The Plan denied your request. The Plan says the denial 
of authorization for this device is correct, because a ventilator is not covered by Medicare for this purpose and 
the enrollee's needs can be met by a bi-level positive airway pressure (BiPAP) device with average volume 
assured pressure support (AVAPS). 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide positive airway 
pressure (PAP) therapy will be denied as not reasonable and necessary, regardless of the underlying medical 
condition.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for the requested purpose. 
The Plan says that they will consider coverage for a BiPAP device with AVAPS mode if requested. Please 
contact the Plan for more information regarding the enrollees treatment options. Based on this information, we 
decided that Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression device provided on July 28, 2021. 
 
You asked the Plan to pay for the service provided. You say that the device was issues for the enrollee to use 
during their surgery. The Plan denied your request. The Plan says payment for this service is the responsibility 
of the facility. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. We looked at the file and the rules. The facility must furnish all necessary covered services to the beneficiary 
either directly or under arrangements made with outside providers. This service was provided via arrangement 
of the facility. Payment for this service would have been included under the facility claim. Payment to you for 
this service is the responsibility of the facility. Therefore, we decided that the Plan does not have to pay for the 
compression device provided on July 28, 2021.
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 daily 
skilled services are not necessary. Our physician reviewer found you received oral medications, had stable vital 
signs and used oxygen via nasal cannula. You were at a standby assist to contact guard assist level for 
functional mobility including gait to 100 feet. You do not require skilled nursing or therapy services on a daily 
basis, and you do 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete replacement of the shoulder joint (23472). 
 
You asked the Plan to pre-approve the complete replacement of the shoulder joint. You say that this procedure 
is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage 
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 the complete replacement of the 
shoulder joint. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee is a 67-year-old male who was being 
treated for other specific arthropathies, left shoulder. He presented with persistent left shoulder pain for greater 
than 1 year. An exam reveals tenderness of the biceps, acromioclavicular joint, and tuberosity. The range of 
motion is forward elevation 160 with pain; external rotation 45; internal rotation L1. Strength is 4/5 in forward 
elevation and external rotation. Cross arm testing, Neers, Hawkins, and Yergasons were all positive. 
 
 However, detailed documentation is not evident regarding any previous left shoulder surgeries, including, but 
not limited to, rotator cuff repair. The magnetic resonance imaging scan does demonstrate full-thickness 
complete tear of the supraspinatus and infraspinatus tendons with advanced fatty replacement of the muscle 
bellies; high-grade partial-thickness tear of the subscapularis tendon; rupture of the long head of biceps tendon; 
acromioclavicular and glenohumeral osteoarthritis. However, it is not evident that this tear would be considered 
irreparable or that a rotator cuff repair could not be utilized versus the requested reverse total shoulder 
arthroplasty. The rationale is not evident in the examinations provided for review. 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 complete replacement of the shoulder joint (23472) 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 the complete replacement of the shoulder joint have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the complete replacement of the shoulder joint (23472).