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

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service February 11, 
2022. 
 You asked the Plan to pay for procedure code 88360. You say that you disagree with the denial. 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 88360 has a Professional/Technical indicator of 1. This means that CPT code 88360 has 
both a professional and technical component. In this case, CPT code 88360 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 88360 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 88360 billed for date of service February 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641-26 billed for date of service August 1, 
2022. 
 
You asked the Plan to pay for procedure code 76641-26. You say that the patient had multiple exams on this 
date of service. 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 76641-26 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 76641-26 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641-26 billed for date of service August 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
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 the additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. The requested visits are not medically reasonable or necessary. Our physician reviewer found that 
the additional requested therapy generally is not accepted as specific and effective therapy for the patients 
condition beyond what was approved by the health plan. The patient has had prior therapy and the 
documentation does not reveal that the patient's requires the unique skills of a professional therapist to safely 
and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, 
or by or under the supervision of a therapist. The requested services are not part of a maintenance program, and 
the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. The 
patient can transition to an independent home exercise program. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on July 27, 2022. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the diagnosis is medication management of long term (current) drug therapy. The medical record 
sent by the provider shows a definitive urine drug test panel for multiple drug classes was performed, but does 
not show screening test results which are positive or inconsistent with prescription medications, dosing 
schedules, or history and expected results. The requested definitive drug testing at issue in this case 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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing provided on July 27, 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 you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status 
does not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that your 
high functional level requires this therapy on an intensive IRF level. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 8, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should not be a bundled service. The 
Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95910 and 95886 provided on May 27, 
2022. 
 
You asked the Plan to pay for procedure codes 95910 and 95886. You say that the medical records support the 
billing of codes 95910 and 95886. The Plan denied your request. The Plan says the medical records do not 
support the billing of codes 95910 and 95886. 
 
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 95910 is Nerve conduction studies; 7-8 studies. The 
definition of code 95886 is Needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles 
studied, innervated by three or more nerves or four or more spinal levels (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 procedure codes 95910 and 95886. Our reviewer says that 
the medical records do not support the billing of codes 95910 and 95886. Our reviewer found during this 
surgery; no nerve conduction studies (NCS) were done. Rather, the member only underwent triggered EMG 
testing (for pedicle screws). Such testing is considered to be part of the EMG services, and are not supposed to 
be coded as a NCS. As a NCS was not done, the records cannot be said to support code 95910. 
 
The records did not support performance of a NCS. As a NCS was not done, the code 95886 submitted would 
not have been the most appropriate code which could be used to reflect the procedure/services 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 procedure codes 95910 and 95886 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 95910 and 95886 provided on May 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from February 
16, 2022 to March 17, 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 NOA was not received timely. As such, this final claim was correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 20, 2021. The NOA has the admit date as January 17, 2022. As 
more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on this 
claim. Therefore, we decided that the Plan does not have to pay for home health services provided to the 
enrollee from February 16, 2022 to March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance provided on June 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan is vague about benefit frequencies, and 
they should work on a calendar year. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on dates of service August 2, 2021, and 
December 2, 2021. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance 
provided on June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on May 4, 
2022. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says a valid proof of delivery 
was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The submitted delivery ticket does not contain an 
itemized list of the items delivered. As such, the records do not show that the item in question was delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) provided 
on May 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided during an outpatient 
hospital stay from September 7, 2022, to September 9, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you were given antacid medication to 
prevent severe bleeding that could be life threatening. The Plan denied your request. The Plan says self-
administered drugs are not covered. 
 
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 pay for self-administered drugs provided 
during an outpatient hospital stay from September 7, 2022, to September 9, 2022.   
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on March 4, 
2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you are disputing the share cost. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $90 
copayment for emergency care.  
 
You have been asked to pay $90 copayment for emergency care. This item/service falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on 
March 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 64447-LT billed for July 29, 2022. 
 
You asked the Plan to pay for code 64447-LT. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 payment for CPT code 64447 is not supported in the medical record. Specifically, the submitted 
documentation shows that the billed diagnosis code, S72.411K, is for right-sided fracture. As such, it is 
inappropriate to bill modifier -LT in this case. Based on this information, we decided that Medicare rules for 
coverage of code 64447-LT have not been met. Therefore, we decided that the Plan does not have to pay for 
code 64447-LT billed for July 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on May 24, 2022. 
 
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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on August 3, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the moderate sedation services rendered on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced electronic knee. 
 
You asked the Plan to pre-approve an advanced electronic knee. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided the enrollee's current knee is less 
than a year old. Therefore, coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that payments for repair and maintenance may not 
include payment for parts and labor covered under a manufacturers or suppliers warranty.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an advanced electronic knee have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an advanced electronic knee.
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 you feel that acute rehabilitation would be the best 
option for you. The Plan denied your request. The Plan says the requested level of care exceeds your medical 
needs. 
 
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 was hospitalized after a fall which caused a hip fracture. He was treated surgically and improved. The most recent therapy notes indicate that the enrollee requires only stand-by 
assistance for mobility. He can ambulate household distances with minimal assistance and using a walker. 
 
In this case, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute 
rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. The enrollee continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement; however, the documentation does not 
support that he would meet criteria for admission to an acute 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee on December 18, 
2021 to December 22, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that the services billed are not supported by the records. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review indicates that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee on December 18, 2021 to December 22, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
January 19, 2021. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says a 
corrected claim was not submitted within the year time frame. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until July 20, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit provided on January 19, 2021.