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

 
We decided that the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel 
(87798 and 87481) provided on May 10, 2022. 
 
You asked the Plan to pay for the fungal infection PCR panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says PCR testing is not indicated as the following are 
appropriate means to verify fungal infection: direct microscopic examination with potassium hydroxide, fungal 
culture of desquamated subungual material, or fungal stain of a nail clippings fixed in formalin. 
 
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 fungal infection PCR panel. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that in this case the enrollee was noted to have a clinical diagnosis of onychomycosis. Clinical appearance of all toenails appeared as onychomycosis. Current accepted standards of 
medical practice for evaluation of fungal presence in a toenail can be performed utilizing very straightforward 
and simple lab tests, including a KOH and fungal culture. These tests can be both sensitive and specific. It is 
unclear as to why a PCR test was needed to investigate this 84-year-old patients left hallux toenail. Therefore, 
the requested PCR testing of this enrollees toenail was 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 fungal infection PCR panel have not been met. Therefore, we decided that 
the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel (87798 and 
87481) provided on May 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); recording in coma or sleep 
only provided to the enrollee on June 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 95822 26 (1 Unit) 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 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep 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 that the technical report does indicate 
that an EEG was performed. However, this code is not supported as the enrollee was not in a coma or sleep. 
There are more appropriate codes to use in this clinical scenario. (e.g., 95812 and 95813). Therefore, the 
records do not support that CPT 95822: Electroencephalogram (EEG); recording in coma or sleep only was rendered. 
 
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 electroencephalogram (EEG); recording in coma or sleep only provided to the enrollee on June 
10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel 
provided on March 7, 2022. 
 
You asked the Plan to pay for a fungal infection PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says PCR testing is not 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 pay for a fungal infection PCR panel. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that in this case the enrollee's physician has ordered PCR testing on a toenail to 
evaluate for pathogens. Standard of care currently is to utilize both KOH and fungal culture testing to evaluate 
for pathogens in a toenail. These tests prove to be both sensitive and specific and are inexpensive compared to 
PCR testing. PCR testing appears to be beyond the enrollees needs as a KOH and fungal culture is sufficient.  
Therefore, the PCR testing of this enrollees toenail was 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 a fungal infection PCR panel have not been met. Therefore, we decided that the 
Plan does not have to pay for a fungal infection polymerase chain reaction (PCR) panel provided on March 7, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG); recording in coma or sleep 
only provided to the enrollee on May 11, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95822 is "Electroencephalogram (EEG); recording in 
coma or sleep 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 that the technical report does indicate 
that an EEG was performed. However, this code is not supported as the enrollee was not in a coma or sleep. 
There are more appropriate codes to use in this clinical scenario. (e.g., 95812 and 95813). Therefore, the 
records do not support that CPT 95822: Electroencephalogram (EEG); recording in coma or sleep only were rendered. 
 
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 electroencephalogram (EEG); recording in coma or sleep only provided to the enrollee on May 
11, 2022.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 37224 and 75710. We decided that the Plan does not have to pay for 
99153.  
 
You asked the Plan to pay for procedure codes 37224, 75710, and 99153 provided to the enrollee on September 
9, 2022.. You say that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 37224 and 75710.  
 
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 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 for CPT 37224 and 75710. Our reviewer says that an 
operative report was not submitted in the case file.  
 
The plan's denial cites an operative report, but this denial cannot be verified based on what the plan forwarded. 
Therefore, the plan has not substantiated their denial. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
37224 and 75710.  
 
We also decided that the Plan does not have to pay for 99153. 
 
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a 
PE only code and that PE are not payable to the physician for services provided in the facility setting. 
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 99153 have not been met. Therefore, we decided that the Plan does not have to pay for 99153. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a back brace. 
 
You asked the Plan to pre-approve a back brace. You say that the item is necessary. The Plan denied your 
request. The Plan says the cost of the requested item is covered as part the SNF stay. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a back brace is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve a back brace.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 71045 billed for date of service September 
22, 2022. 
 You asked the Plan to pay for procedure code(s) 71045. You say that the claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says this code is included in the skilled nursing facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 71045 has a Professional/Technical indicator of 1. This means that CPT code 71045 has 
both a professional and technical component. In this case, CPT code 71045 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code 71045 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code(s) 71045 billed for date of service September 22, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 16, 2022 to 
April 22, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. The Plan 
denied your request. The Plan says the claim has not been billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from April 16, 2022 to April 
22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
28, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service November 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99232 provided on July 15, 2022. 
 
You asked the Plan to pay for procedure code 99232. You say that this service was medically necessary. The 
Plan denied your request. The Plan says that this code was included in another procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The records provided by the plan do not show what other procedure was billed. 
Without this information, it cannot be determined if the billed code is inclusive to another procedure. 
Therefore, we decided that the Plan has to pay for procedure code 99232 provided on July 15, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240) and a raised toilet seat (E0244). 
 
You asked the Plan to pre-approve a shower chair and a raised toilet seat. You say that the requested items are 
a medical necessity for you. The Plan denied your request. The Plan says these items are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not 
covered because they are not primarily medical in nature.  
 
While a shower chair and a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare 
offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a shower chair 
(E0240) and a raised toilet seat (E0244).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of a spinal cord stimulator. 
 
You asked the Plan to pre-approve the placement of a spinal cord stimulator. You say that the clinical 
information provided supports the need for the requested procedure. The Plan denied your request. The Plan 
says there is no clinical information showing that the enrollee has had a psychological screening. 
 
The Plan follows Medicare rules. Medicare rules say that the implantation of spinal cord stimulators is covered 
for certain indications.   
 
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 placement of a spinal cord 
stimulator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found 
the case file does not contain documentation of an extensive discussion of the risks and benefits of a spinal cord 
stimulator, nor is appropriate psychological screening documented.  
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 placement of a spinal cord stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the placement of a spinal cord stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal polymerase chain reaction (PCR) panel (87798, 
87481) provided on March 15, 2022. 
 
You asked the Plan to pay for the fungal PCR panel. You say that PCR testing is not indicated as the following 
are appropriate means to verify fungal infection: direct microscopic examination with potassium hydroxide, 
fungal culture of desquamated subungual material, or fungal stain of a nail clippings fixed in formalin. The 
Plan denied your request. The Plan says this testing was 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 pay for the fungal PCR panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that it is well established that this enrollee is suffering with thickened, dystrophic, 
painful toenails. Standard of care currently is to evaluate toenails for fungus utilizing KOH and fungal culture.  
These tests are inexpensive and demonstrate both specificity and sensitivity. Medicare guidelines advise that 
they will indeed pay for items or services used to diagnose or treat a malformed body member. These tests must be safe and effective, not mainly for the convenience of the patient or the physician and furnished 
appropriately in accordance with the patients needs. These services must be not experimental or 
investigational and at least as beneficial as commonly available treatments. In this particular case it appears 
excessive for this enrollees toenail to be tested with PCR. It is unclear as to why this physician could not have 
ordered a KOH and fungal culture, both of which are considered standard of care for evaluation of pathogens in 
toenails. Therefore, it is my opinion that the requested PCR testing for this enrollees toenail was 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 fungal PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the fungal polymerase chain reaction (PCR) panel (87798, 87481) provided on March 
15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary to ensure a full recovery 
for the enrollee. The Plan denied your request. The Plan says the services can be provided safely in another 
setting such as, a skilled nursing facility, home with home health services, or home with outpatient therapy. 
  
 
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 does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies have not proven that this procedure is helpful for treatment. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that this procedure is experimental for back pain. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.