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

 
We decided that the Plan does not have to pay for laparoscopy, surgical, repair of paraesophageal hernia, 
includes fundoplasty, when performed; without implantation of mesh (43281-59) provided on August 19, 2021. 
 
You asked the Plan to pay for the surgical laparoscopy. You say that this service is supported as billed. The 
Plan denied your request. The Plan says code 43281 is not supported in the medical record. The operative 
report did not include documentation of surgical laparoscopic repair of paraesophageal hernia, which includes 
fundoplasty, when performed; without implantation of mesh; therefore, this code 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 43281 is laparoscopic repair of paraesophageal hernia, 
includes fundoplasty, when performed; without implantation of mesh. 
 
 
 
  
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 surgical laparoscopy. Our reviewer says that the 
requested service is not supported as billed. Our reviewer found that the operative report does not include 
enough detail to confirm that this procedure has been performed per National Correct Coding Initiative (NCCI) 
Policy Manual standards. This procedure cannot be verified with the documentation submitted. 
 
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 surgical laparoscopy have not been met. Therefore, we decided that the Plan 
does not have to pay for laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when 
performed; without implantation of mesh (43281-59) provided on August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an innerspring mattress. 
 
You asked the Plan to pay for the mattress. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a mattress is covered only when a hospital bed is 
medically necessary.  
 
We looked at the file and Medicare rules. The mattress was not requested to be used with a hospital bed. 
Mattresses are only covered when used with a medically necessary hospital bed. Based on this information, we 
decided that Medicare rules for coverage of the mattress have not been met. Therefore, we decided that the Plan 
does not have to pay for an innerspring mattress.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on September 15, 2021.
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 should be processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 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, and not a licensed therapist. As such, OTA 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 therapy assistant on September 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states your medical and therapy needs can be met in skilled nursing unit.
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 you are medically stable and do not need physical medicine and rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. An uncomplicated post cervical spine surgery, you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. You need therapy at a lower intensity level. IRF admission is not medically necessary based on lack of medical complexity, and lack of acute rehabilitation nursing needs. Document does not support the necessity for admission to an IRF. While you may benefit from physical therapy (PT), and maybe occupational therapy (OT), your rehabilitation needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility (SNF). 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound provided on October 14, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 76705 was billed along with code 93976. We looked at the file and the rules. We 
find that code 76705 may be eligible for payment when billed with this code pair. The claim does not show that 
the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that 
Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for the abdominal ultrasound provided on October 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on the LTACH criteria. The Plan 
states the enrollee's care can be provided in the current inpatient hospital and they may be ready to move to 
another setting in the future. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable but still requires short-term acute care services 
that can be safely administered at the current facility, including weaning trials, until more stable. The enrollee 
does not require services at the LTACH that are not already available at the current facility. There are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a 
lower level of care may be considered when treatment has completed. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the services are available within the network.
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 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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an out-of-network referral.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had acute hypoxic respiratory failure and is improving but still requires 
ongoing critical care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that he is not currently 
receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional units of surgical services provided to the enrollee 
on April 20, 2021. 
 
You asked the Plan to pay for the additional units. You say that this should be paid for. The Plan denied your 
request. The Plan says there is no additional documentation supporting additional services which were billed 
and remain denied. 
 
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 22610: 
 
Arthrodesis, posterior or posterolateral technique, single interspace; thoracic (with lateral transverse technique, 
when performed) 
 
CPT 22614:  
Arthrodesis, posterior or posterolateral technique, single interspace; each additional interspace (List separately 
in addition to code for primary procedure) 
 
CPT 22846: 
 
Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) 
 
CPT 63045: 
 
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical 
 
CPT 63048: 
 
Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda 
equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional 
vertebral segment, cervical, thoracic, or lumbar (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 additional units. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found the enrollee had C5-T2 fusion 
surgery for fracture care. The operative note does not support the additional codes and they should be denied. 
 
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 additional units have not been met. Therefore, we decided that the Plan does 
not have to pay for additional units of surgical services provided to the enrollee on April 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64629 and 64628), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee's pain is disabling, affects their quality of life on a daily basis and has been long-term duration. You state given that you have failed non-operative treatment, the intracept procedure is truly the only solution. The Plan denied your request. The Plan says your request is not medically necessary because there is little evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain. The Plan states it is not an accepted standards of medical practice for the diagnosis or treatment of back pain; therefore, it is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure with basivert nerve ablation is experimental for lower (LBP).
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 the intracept procedure (CPT code(s): 64629 and 64628), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the chest provided 
on October 10, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple procedures on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
The file shows that CPT code 71250 was billed with code 71275. We find that CPT code 71250 may be eligible 
for payment when billed with this code pair. The claim information does not show that the code at issue was 
billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) scan of the chest provided on October 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 24, 2021. 
 
You asked the Plan to pay for the testing services. You say that there is a misinterpretation of guidelines. The 
Plan denied your request. The Plan says the validity and accuracy of the claim cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 The file shows that Guardant360 testing was provided. We looked at the file and the rules. If an independent 
lab bills for services, the place where the sample was taken is reported as the POS. The claim lists the place of 
service as an independent laboratory. The records do not indicate the enrollees specimen was obtained at an 
independent laboratory. 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 services 
provided on July 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you could receive care in another setting. The Plan states they could review alternate settings if requested such as a skilled nursing facility, outpatient setting or home health care.
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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Your medical conditions are stable on outpatient medications with no issues that require a physician's evaluation three (3) or more times per week. You do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to your decreased activity tolerance, pain and weakness. Care at the skilled nursing facility level appears to be 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from June 1, 2020 to June 12, 2020.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says during the audit of this claim, medical records were requested and not provided after multiple attempts to obtain.
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. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of skilled nursing facility (SNF) services provided to the enrollee from June 1, 2020. have not been met. Despite multiple attempts and requests from the plan, the appealing provider did not send any medical records to support payment for these services.. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from June 1, 2020 to June 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. The Plan 
states the services the enrollee needs could be provided in another setting, such as an acute rehabilitation 
facility, skilled nursing facility, nursing facility, outpatient setting or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and requires only short-term acute care services 
that can be safely administered at the current facility until appropriate for a lower level of care. The enrollee 
does not require services at the LTACH that are not already available at the current facility. There are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a 
lower level of care may be considered when treatment has completed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.