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

 
We decided that the Plan does not have to pay for the carpal tunnel injections rendered on November 22, 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 billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that bilateral surgeries must be billed with the -50 
modifier. 
 
We looked at the file and Medicare rules. The file shows that a bilateral procedure was billed without the 
required -50 modifier. Therefore, we decided that the Plan does not have to pay for the carpal tunnel injections 
rendered on November 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from July 17, 2021, 
to July 27, 2021, billed with diagnosis related group (DRG) code 981. 
 You asked the Plan to pay for the inpatient hospital services billed with DRG 981. The Plan denied your 
request. The Plan says DRG 981 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 981: extensive operating room procedure 
unrelated to principal diagnosis with major complications or comorbidity (MCC). 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 inpatient hospital services billed with DRG 981. Our reviewer says 
that the submitted DRG is not supported. Our physician reviewer found the member's diagnoses included chest 
pain with a Non-ST-elevation myocardial infarction (NSTEMI) and diabetic ketoacidosis (DKA) present at 
admission. The member required multivessel percutaneous coronary intervention (PCI) and his DKA 
responded well to initial treatment. Our reviewer found that the criteria for payment under DRG 981, extensive 
operating room procedure unrelated to principal diagnosis with MCC are not supported in the medical records. 
Our physician reviewer also found that the inpatient hospital admission is approved according to DRG 246, 
percutaneous cardiovascular procedures with drug-eluting stent with MCC or 4+ vessels or stents.  
 
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 the inpatient hospital services provided from July 17, 2021, to July 27, 2021, billed with diagnosis related 
group (DRG) code 981.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
September 14, 2021, to October 13, 2021. 
 
You asked the Plan to pay for home health services. You say that you were advised by a plan representative 
that a RAP was not needed in order to process claims. The Plan denied your request. The Plan says no 
exception request was submitted to waive the 55-day requirement for filling the RAP claim due to a 
circumstance beyond the provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date, September 14, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee from September 14, 2021, to 
October 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
(A0998) provided on November 6, 2021. 
 
You asked the Plan to pay for the ambulance response without transport. You say that you passed out due to 
heat and people around you called emergency medical services. You did not need hospital care and feel this 
charge is exorbitant for the services provided. The Plan denied your request. The Plan says the ambulance 
benefit is a transportation benefit. When no transport is provided, there is no payable service. 
 
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 November 6, 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 the ambulance response and treatment without 
transport (A0998) provided on November 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as at a skilled nursing facility, on an intermittent basis at home with home health care, or in a 
long-term care setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee's rehabilitation needs can be met safely and provided at a lower 
intensity and alternate setting such as in a skilled nursing facility or in-home with home health services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for assistant surgeon services for a vertebral corpectomy provided to the 
enrollee on August 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 that the denied procedure code is not supported by the medical records submitted. 
 
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 63085 is Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach 
with decompression of spinal cord and/or nerve root(s); thoracic, single segment. 
 
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 supported by the medical records. Our reviewer found the enrollee underwent an exploration of 
fusion, partial corpectomy of T9 with revision laminectomy T9-10 and extension of fusion to T4 with robotics 
on 8/23/21. The procedure notes the transpedicular approach was continued and a partial corpectomy with the 
removal of the remainder of the disc and material as well as any loose fragments within the disc space itself. 
Approximately 50% of the posterior vertebral body was removed. Therefore, the records to support that a 
vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with 
decompression of spinal cord and/or nerve root(s); thoracic, single segment (CPT 63085) was rendered in this 
case.  
 
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 been met. Therefore, we decided that the Plan has to pay for 
assistant surgeon services for a vertebral corpectomy provided to the enrollee on August 23, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee requires 
total help by another to change positions in bed, move from bed to chair and to walk, but they do not require 
intensive medical treatment for their hip injury. The Plan also says that this request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the patient does require physical therapy and occupational therapy services, but the medical records 
provided do not clarify why the patient requires an intensive inpatient rehabilitation therapy program. Our 
physician reviewer also found that there is no documentation that the patient requires the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 17, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. The 
Plan denied your request. The Plan says The rendering provider is non-par and there isnt a referring provider. 
Also, there is no evidence that this is urgent or emergent. 
 
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 requested 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 an office visit 
provided on November 17, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392) to be provided 
by an out of network provider. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you must carry an oxygen tank 
everywhere you go but it is difficult due to your weakness. You want this one because it has a fanny pack that 
will enable you to get out of your home and go to your appointments with ease of carrying oxygen. The Plan 
denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 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 pre-approve care from out-of-network providers 
only in cases involving emergencies, out of area urgent care and care that cannot be provided by network 
providers. 
 
The file shows that you have a portable oxygen e-tank which serves the same purpose as the requested portable 
oxygen concentrator. The requested provider in this case is not a network provider with the Plan. The Plan has 
network providers available who can provide the items/services at issue in this appeal.  Therefore, we decided 
that the Plan does not have to pre-approve a portable oxygen concentrator (E1392) to be provided by an out of 
network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc (J7325). 
 
You asked the Plan to pre-approve Synvisc. You say that the enrollee needs the Synvisc injection on her hip. 
The Plan denied your request. The Plan says Original Medicare does not cover this drug for the diagnosis code 
the doctor's office provided to describe the enrollee's health condition. 
 
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation of joints other than the 
knee(s) are considered not reasonable and necessary and are not subject to coverage.  
 
We looked at the file and Medicare rules. The record shows that this injection is supposed to be administered 
for the enrollee's hip. Based on this information, we decided that Medicare rules for coverage of Synvisc have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for drainage of an abdominal abscess or infection (49020-51) provided on 
November 10, 2021. 
 
You asked the Plan to pay for surgical procedure 49020-51. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says that the denial of payment for this service is correct, 
because code 49020-51 is inclusive to code 48105 and cannot be verified for payment. 
 
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. Medicare rules say that providers must report services correctly. Providers must report services with 
the appropriate CPT code. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit medical records for review. You submitted supporting 
medical records to the Plan, but these records were not submitted to us. Without supporting records, we cannot 
determine whether the use of code 49020-51 is appropriate and payable on this claim. Therefore, the Plan has 
not shown that its decision to deny payment for code 49020-51 is correct or justified according to Medicare 
rules. Therefore, we decided that the Plan has to pay for drainage of an abdominal abscess or infection (49020-
51) provided on November 10, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (CPT code 99152) provided on July 
29, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not indicate the presence of an independent trained 
observer to assist in the monitoring of the enrollee's level of consciousness and physiological status; therefore, 
the billed service cannot be verified. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
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 found the documentation 
submitted did not indicate the presence of an independent trained observer during the procedure for the billed 
services. There was documentation that Versed, and Fentanyl were administered, however, there was no 
anesthesiology record documenting intraoperative/intra-procedural monitoring of this patient (including blood 
pressure, heart rate, respiratory rate, EKG, oxygen saturation).  The reviewed has determined that the use of 
CPT 99152 is not supported by the records provided. 
 
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 the anesthesia services (CPT code 99152) provided on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D rendering services provided to the enrollee on December 
16, 2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says Current Procedural Terminology (CPT) code 76377 (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 76377 is "3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation." 
 
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 use of CPT 76377 or 3D rendering 
must be supported in the report by way of description of the procedure and documentation of the medical 
necessity of the additional rendering which is then done at a separate workstation. These elements are not included in the report of the magnetic resonance cholangiopancreatography (MRCP) 
and thus separate 3D rendering is not reimbursable.   
 
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 3D rendering services provided to the enrollee on December 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy (PT) visits. 
 
You asked the Plan to pre-approve continued PT visits. The Plan denied your request. The Plan says the 
requested service does not meet medical necessity criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the member has previously been treated with outpatient therapies and 
should be independent with a home exercise program. Our reviewer found that there is no documentation of a 
recent injury or decline in function. Our physician reviewer also found that the additional therapy services are 
not an appropriate duration and frequency for treatment of the members medical 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 continued PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks (64493, 64494). 
 
You asked the Plan to pre-approve medial branch blocks. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested 
services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a facet joint procedure performed after anterior 
lumbar interbody fusion (ALIF) is considered not medically reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of medial branch blocks have not been met. Specifically, the case record documents that the enrollee has received an ALIF procedure. Therefore, we decided that the Plan does not have to pre-approve medial 
branch blocks (64493, 64494).