Persius/hicric huggingface dataset:
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 Medicare coverage criteria are not met. 
 
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 nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex 
nursing or rehabilitation needs.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve L5973 microprocessor ankle/foot system. 
 
You asked the Plan to pre-approve L5973 microprocessor ankle/foot system. You say that this item is 
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 L5973 
microprocessor ankle/foot system. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the  L5973 microprocessor 
ankle/foot system exceeds the patient's medical needs and is not proven superior to a standard socket therefore 
does not meet Medicare medically necessary criteria per Local Coverage Determination (LCD): Lower Limb 
Prostheses (L33787) and the related Local Coverage Article (A52496) and the Social Security Act, Section 
1862 (a)1(A) and the 42 CFR 411.15(k), as Medicare does not pay for any items or services that are not 
reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member. The progress reports do not support the prosthetists (vendor) documentation that 
you require a microprocessor knee over a standard K3 mechanical knee.  There is no discussion in the PA-C medical progress notes indicating that your needs cannot be met with a 
mechanical K3 knee. Medicare coverage criteria are not met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L5973 microprocessor ankle/foot system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve L5973 microprocessor ankle/foot system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (99100) provided on June 14, 2021. 
 
You asked the Plan to pay for the anesthesia (99100). You say that the completed medical records should be 
reviewed, and the claim processed for payment. The Plan denied your request. The Plan says CPT code 00731 
has been overturned and CPT code 99100 remains denied as bundled services are not eligible for separate 
reimbursement. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (99100) provided on July 27, 2021. 
 
You asked the Plan to pay for the anesthesia (99100). You say that you are supposed to be paid $45 for this 
charge per your contract. The Plan denied your request. The Plan says CPT code 00942 has been paid and CPT 
code 99100 remains denied as bundled services are not eligible for separate reimbursement. 
 
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 99100 is anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 
 
 
  We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status 
indicator of B. This means that CPT code 99100 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the anesthesia (99100) have not been met. 
Therefore, we decided that the Plan does not have to pay for the anesthesia (99100) provided on July 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood smear interpretation provided on July 21, 2021, 
billed with code 85060. 
 
You asked the Plan to pay for the services as billed. You say that this is billed correctly and should be paid in 
full. The Plan denied your request. The Plan says 85060 is not payable in the reported place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Code 85060 has a pro-tech flag of "8" in the Physician Fee Schedule. This indicator identifies the professional 
component of clinical laboratory codes for which separate payment may be made only if the physician 
interprets an abnormal smear for hospital inpatient. No payment is recognized for CPT code 85060 furnished to 
hospital outpatients or non-hospital patients.  
 The file shows that the enrollee was a hospital outpatient on this date of service, meaning no payment can be 
made for this code. Based on this information, we decided that Medicare rules for coverage of the services as 
billed have not been met. Therefore, we decided that the Plan does not have to pay for a blood smear 
interpretation provided on July 21, 2021, billed with code 85060.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myobloc. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Myobloc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fentanyl. 
 
You asked the Plan to pre-approve Fentanyl. The Plan denied your request. The Plan says Fentanyl is a benefit 
exclusion. The Plan also says that drug coverage is limited only to those drugs covered under the enrollee's 
medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fentanyl.  
 
Benefits for Fentanyl 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services provided on October 8, 2021.  
 
 
You asked the Plan to pay for the testing services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
In this case, the CPT Code Manual definition of code 95812 is electroencephalogram (EEG) extended 
monitoring; 41-60 minutes, CPT code 95885 is needle electromyography, each extremity, with related 
paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited 
(List separately in addition to code for primary procedure) and CPT code 95911 is nerve conduction studies; 9-
10 studies. 
  
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 testing services. Our reviewer found CPT code 95812-26 
is not supported by the medical records. It is noted that continuous EEG monitoring was performed throughout 
the surgical procedure. However, EEG extended monitoring for 41 - 60 minutes is not documented in the 
Technical Report. CPT code 95885-26 x2 is not supported by the medical records. It is documented that free 
running lower EMG responses were recorded from five muscles throughout the procedure. No significant EMG 
activity was observed. However, documentation of limited needle electromyography, per each extremity with 
related paraspinal areas when performed, done with nerve conduction, amplitude, and latency/velocity study is 
not documented in the Technical Report. CPT code 95911-26-59 is not supported by the medical records. 
Documentation of nerve conduction studies, 9 - 10 studies, is not present in the Technical Report. 
 
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 testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the testing services provided on October 8, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the breast ultrasound you had on August 24, 2021. 
 
You asked the Plan to waive the deductible for the breast ultrasound. You say that this test should be 
considered part of your preventive mammogram and no cost sharing should apply. The Plan denied your 
request. The Plan says that the ultrasound you had is not a preventive service, so the deductible applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $395 deductible that applies to the following services: dialysis 
services, inpatient hospital services, inpatient mental health, outpatient hospital services, outpatient 
observation, skilled nursing facility care, therapeutic radiology services, and x-rays. 
 
The Plan says you must pay a $395 deductible for the breast ultrasound. We do not agree.  The language in 
your contract explicitly limits the deductible to only applying to certain services. The Plan claims that the 
contract says that the deductible applies to x-rays.  That is true.  However, an ultrasound is not an x-ray.  It is 
not appropriate for the Plan to apply cost sharing for an x-ray to an ultrasound service when they are totally 
different diagnostic tests.  There is nothing in your contract that says that the deductible would apply to an 
ultrasound. Therefore, we decided that the Plan has to waive the deductible for the breast ultrasound you had 
on August 24, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic supplies provided by an illegible provider on 
September 10, 2021. 
 
You asked the Plan to pay for the diabetic supplies. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider has not enrolled in the Medicare 
program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided by an 
illegible provider on September 10, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Removal of impacted cerumen using irrigation/lavage (69209) 
provided on August 13, 2021. 
 
You asked the Plan to pay for code 69209. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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 69209 is Removal impacted cerumen using irrigation/lavage, unilateral. 
 
We find that CPT code 69209 is supported in the medical record. Specifically, the records show that only the 
right ear was treated. Medicare only allows up to 2 units to be reported for this code. As the records show that 
only the right side was treated, the claim was submitted with one unit correctly. An anatomical modifier is not 
required in this case for payment to be considered. Based on this information, we decided that Medicare rules 
for coverage of code 69209 have been met. Therefore, we decided that the Plan has to pay for the Removal of 
impacted cerumen using irrigation/lavage (69209) provided on August 13, 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 introduction of needle or intracatheter (36140) provided 
on April 1, 2021. 
 
You asked the Plan to pay for the introduction of needle or intracatheter (36140). You say that procedure code 
36140 has been denied as bundled but it is documented in the provider's procedure note. You say that the claim 
should be reviewed again. The Plan denied your request. The Plan says procedure codes 37246, 36902, 36907, 
75710, and 76937 were approved. The Plan also says that CPT code 36140 remains denied as it is inclusive to 
36902. 
 
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 36140 is a column II code to column I code 36902; however, 36140 
was billed with a modifier.  
 
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 introduction of needle or intracatheter (36140). Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the documentation does not support this service was performed at different anatomical site, 
and therefore cannot be verified. This procedure would be inclusive to CPT 36902. 
 
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 introduction of needle or intracatheter (36140) have not been met. 
Therefore, we decided that the Plan does not have to pay for the introduction of needle or intracatheter (36140) 
provided on April 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the malignant lesion excision (11604) provided on October 
21, 2021. 
 
You asked the Plan to pay for the malignant lesion excision (11604). You say that the operative report 
distinctly states excision of the lesion, and its margins takes place into the subcutaneous tissue with no 
evidence of any residual scar depth and the excision measured 3.1 cm. You say that the operative note and 
pathology report should be reviewed and payment for 11604 should be reprocessed. The Plan denied your 
request. The Plan says procedure code 11604 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 11604 is excision, malignant lesion including margins, 
trunk, arms, or legs; excised diameter 3.1 to 4.0 cm.  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 malignant lesion excision (11604). Our reviewer says that 
the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found 
that the operative report does not include sufficient documentation to confirm an excision of malignant lesion 
was performed. Therefore, the procedure cannot be verified, and a more appropriate code should be reported 
that the documentation supports. 
 
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 malignant lesion excision (11604) have not been met. Therefore, we decided 
that the Plan does not have to pay for the malignant lesion excision (11604) provided on October 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) computed 
tomography (CT) scan from the skull to thigh (78815). 
 
You asked the Plan to pre-approve a PET CT scan from the skull to thigh. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS continues to nationally non-cover initial 
anti-tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PET CT scan from the skull to thigh have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a positron emission tomography (PET) computed tomography (CT) scan from the skull 
to thigh (78815).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 26, 
2020, to April 28, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the entire stay/level of care was 
appropriate, medically reasonable and necessary. The Plan denied your request. The Plan says this admission 
did not meet inpatient criteria level of care. 
 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 the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found there was no indication that the enrollee would require hospital services 
that would likely cross 2 midnights. Our reviewer also found that a lower level of care would have been more 
appropriate. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from April 26, 2020, to April 28, 
2020.