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

 
We decided that the Plan does not have to pay for adjacent tissue transfer/rearrangement services provided to 
the enrollee on July 9, 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 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 14060 is Adjacent tissue transfer or rearrangement, 
eyelids, nose, ears and/or lips; defect 10 sq cm or less. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the operative report does not 
describe additional incisions made to create a flap that slides or advances forward from its normal location into 
a defect for repair. In this case, adjacent tissue transfer cannot be verified.  
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 adjacent tissue transfer/rearrangement services provided to the enrollee on July 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for morphometric analysis provided to the enrollee on December 
1, 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 test at issue is investigative. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the reviewed documentation indicates that the records demonstrate that the patient had a bone marrow 
biopsy suggesting leukocytosis. Without a diagnosis of a myeloid disease or myeloproliferative disorder, these 
tests are considered not medically necessary. The review has determined that the services at issue in this case are 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for morphometric analysis provided to the enrollee on December 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transesophageal echocardiography services provided to the 
enrollee on November 23, 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 93313 is "Echocardiography, transesophageal, real-time 
with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe 
only." 
 
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 provider is reporting 
transesophageal echocardiogram (TEE) placement with anesthesia services. The procedure report does not 
include documentation to confirm criteria for separate billing. In cases when the anesthesiologist places the probe and another physician maintains the image acquired and does a written interpretation and report, the 
placement-only diagnostic TEE code 93313 is used with the 59 modifier. In order for the diagnostic TEE probe 
placement to be payable, some payers will be requiring the corresponding image acquisition, interpretation and 
report to be billed by the other physician. 
 
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 transesophageal echocardiography services provided to the enrollee on November 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zioptan drops 0.0015% for the enrollee. 
 
You asked the Plan to pre-approve the drops. You say that this is medically necessary. The Plan denied your 
request. The Plan says this self-administered medication does not fall under Part B coverage. 
 
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 Zioptan drops 0.0015% for 
the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by a 
network facility. 
 
 
 You asked the Plan to pre-approve the SNF care. You say that you would benefit from therapy and the SNF 
will help you to regain strength. The Plan denied your request. The Plan says authorization denied because the 
SNF care is not medically necessary, and your needs can be met at a lower level of care such as home with 
supervision. 
 
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found service needs that require skilled nursing 
services, including the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment. There are identifiable skilled 
therapy service needs that require skilled therapy services, including the specialized skill, knowledge and 
judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable 
treatment. You do not require skilled nursing or therapy services on a daily basis. The records provided do not 
show a significant decline your functional status to necessitate daily inpatient skilled therapy services. As a 
practical matter, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting. The records do not show that services in a long-term care facility on a part time 
basis are not appropriate in this case.  
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services (2 weeks for teaching/glucose 
testing and nursing visits three times a week for 60 days). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says  
 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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found you were recently 
diagnosed with diabetes, for which home health skilled nursing facility services have been ordered. Such 
services are medically necessary and reasonable for the purpose of diabetic teaching and initial supervision. 
The health plan has approved fourteen home health skilled nursing visits to provide these services. The health 
plan is currently denying additional services. This denial is appropriate as ongoing services are not yet 
documented to be medically necessary and reasonable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services (2 weeks for teaching/glucose testing and nursing visits three times a 
week for 60 days).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx test provided to the enrollee on September 
18, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no clinical information about this patient included in the submitted documentation. 
 
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 the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review indicates that this testing should be done only in very healthy people with little or no 
comorbidities (especially if they have never undergone PSA testing or have a rising PSA) to detect the small 
number of aggressive cancers that pose a significant risk if left undetected until signs or symptoms develop. In this case, there is no clinical information about this patient. Without this information, this testing would not be 
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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the SelectMDx test provided to the enrollee on September 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is a medically necessary 
procedure. The Plan denied your request. The Plan says the requested procedure is experimental. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found Food and Drug Administration (FDA) indications include implantation of the 
Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom 
operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees 
of spinal stenosis, many not at FDA indicated levels of moderate spinal stenosis (including the planned level 
of implantation at L2-3). FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, 
and have not been adequately addressed in the medical records. There is imaging evidence of spondylolisthesis, 
with no discussion of spinal instability on flexion/extension films. There is no documentation of the enrollees 
height, weight or body mass index. There is imaging evidence of levoscoliotic curvature of the lumbar spine, with no documentation of the Cobb angle.  
 
Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion 
interspinous spacer at L2-3 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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on October 6, 
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 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 38724: 
 
Cervical lymphadenectomy (modified radical neck dissection) 
 
CPT 14040: 
 
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 38724, the 
operative report does not describe a lymphadenectomy, and therefore cannot be verified. In terms of CPt 
14040, the operative report does not describe adjacent tissue incised and transferred over to close a wound 
defect. In this case, this procedure cannot be verified. 
 
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 provided to the enrollee on October 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for venography and related services provided to the enrollee on 
September 7, 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 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 36005: 
 
Injection procedure for extremity venography (including introduction of needle or intracatheter) 
 
CPT 36012: 
 
Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus) 
 
CPT 75820: 
 
Venography, extremity, unilateral, radiological supervision and interpretation 
 
CPT 75825: 
 
Venography, caval, inferior, with serialography, radiological supervision and interpretation 
 
CPT 93770: 
 
Determination of venous pressure 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 36005, the 
procedure code was not reported with a modifier. When procedure to procedure (PTP) has a modifier indicator 
of 1, an appropriate modifier should be appended. In terms of CPT 36012, the operative report does not include 
documentation to confirm a second order venography. This procedure cannot be verified, in documentation 
submitted. In terms of CPT 75820 and 75825, although these procedures are documented in the operative 
report, these procedures would be inclusive to CPT 37238 per the code description "including radiological 
supervision and interpretation." The services were improperly unbundled. In terms of CPT 93770, status 
indicator B indicates a service that is always bundled into another service. Reimbursement of this service is 
always included in the payment for another service, whether the code is billed on the same date of service as a 
primary code or billed alone on a different date or claim. Therefore, this procedure would not be covered. 
 
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 venography and related services provided to the enrollee on September 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosentyx for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this drug is self-administered, and covered under the pharmacy benefit. 
 
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 for the enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a lumbar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve the requested ESI. You say that it is felt that this is a necessary treatment. 
The Plan denied your request. The Plan says that there is insufficient documentation of conservative 
management. 
 
{***Add rules/contract recap and to complete decision section. For example: 
 
"The Plan follows Medicare rules. Medicare rules say that [insert custom text from glossary].***} 
 
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 requested ESI. Our reviewer says 
that the requested ESI is medically necessary. Our physician reviewer found the enrollee is a male with chronic 
low back pain with radiation to his leg. On advanced imaging, multi-level degenerative disc disease, facet 
arthropathy as well as an extruded disc at L2-L3 were reported. He is taking Mobic and Ibuprofen. He attended 
Physical Therapy and is doing Home exercise. The request is for an Epidural Steroid injection. The request 
meets all criteria of the LCD.  =The request is medically reasonable and 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 requested ESI have been met. Therefore, we decided that the Plan has to 
pre-approve a lumbar epidural steroid injection (ESI).  
 
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 pay for portable x-ray services provided to the enrollee 
 
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 a nursing home is an excluded place of service for portable x-rays. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99222, 74230, and 72040 are not supported in the medical record. Specifically, a place 
of service of nursing home is inappropriate for this service. 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 portable x-ray services provided to the enrollee
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 4, 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 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 49020: 
 
Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open 
 
CPT 49905: 
 
Omental flap, intra-abdominal (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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 49020, the 
operative report describes drainage of peritoneal abscess with closure. In this case, the drainage was not 
performed for other than the ulcer repair. Therefore this procedure would be inclusive to CPT 43840. In terms 
of CPT 49905, the documentation does not include enough documentation to verify the required elements for 
this procedure. Dissection from stomach and transverse colon, division and ligation of vessels and 
mobilization, and fixation of flap. Therefore this procedure would not be covered. 
 
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 provided to the enrollee on August 4, 2021.