Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee brace provided to the enrollee on November 10, 2021. 
 You asked the Plan to pay for the brace. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no visit with the doctor regarding the brace. 
 
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 brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the records do not show any evidence of knee instability or acute fracture. The brace was not medically 
needed, and was not ordered by a physician. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pay for a knee brace provided to the enrollee on November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repair of a hospital bed. 
 
You asked the Plan to pre-approve the repair of a hospital bed. 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 the repair of equipment is covered under certain 
circumstances. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the repair of a hospital bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the repair of a hospital bed.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you received oral medications, had 
stable vital signs and received ongoing uncomplicated wound care. You were at a dependent to maximal assist 
level with functional mobility and non-ambulatory. You do not require skilled nursing or therapy services on a 
daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
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 July 
29, 2020, to August 24, 2020. You asked the Plan to pay for home health services. You say that this should be paid for. The Plan denied your 
request. The Plan says the provider failed to submit a plan of care for the dates of service billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, The provider 
did not send in a plan of care for these services.. Therefore, we decided that the Plan does not have to pay for 
the home health services provided to the enrollee from July 29, 2020, to August 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered on August 12, 2021 to 
August 13, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services 
were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion 
therapy rendered on August 12, 2021 to August 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided 
September 7, 2021 to October 19, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that you were told you were covered for 
individual outpatient psychotherapy. The Plan denied your request. The Plan says services rendered by a 
licensed marriage and family therapist are not covered. 
 
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 individual psychotherapy services 
(90834) provided September 7, 2021 to October 19, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for molecular genomic testing provided to the enrollee on Sept 4, 2020. 
 
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 this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that there must be an underlying performance of 
acceptable, high-quality analytical validity for all laboratory testing. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found adenocarcinoma of the esophagus that has metastasized carries a poor prognosis. Treatment algorithms 
exist with recommendations for testing the tumor for micro satellite instability (MSI), HER2 and PDL-1. All of 
these markers have therapeutic and prognostic indications. Molecular profiling/next generation sequencing 
(NGS)  helps identify patients for whom targeted agents might already exist and for possible clinical trials. This 
was in effect when the enrollee was tested on 9/4/2020. The service was reasonable and medically 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 services have been met. Therefore, we decided that the Plan has to pay for 
molecular genomic testing provided to the enrollee on Sept 4, 2020.  
 
 
 
 
 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 13, 2020. 
 
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 lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (95886) and nerve conduction 
studies (95909) provided on May 3, 2021. 
 
You asked the Plan to pay for the needle electromyography (95886) and nerve conduction studies (95909). You 
say that intraoperative monitoring is utilization of sensory and motor monitoring techniques that help protect 
patients during surgical intervention. You say that CPT codes 95886 and 95909 were medically necessary and 
payment should be allowed at the in-network benefit. The Plan denied your request. The Plan says CPT codes 
95886 and 95909 are 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 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). The CPT Code Manual definition of code 95909 is nerve 
conduction studies; 5-6 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 needle electromyography (95886) and nerve conduction 
studies (95909). Our reviewer says that the documentation submitted was reviewed and does not meet the 
criteria for coverage. Our reviewer found that the technical report describes pedicle screw stimulation was 
performed and reported with nerve conduction studies. Nerve conduction studies would not be reported for 
pedicle screw stimulation. 
 
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 needle electromyography (95886) and nerve conduction studies (95909) 
have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography 
(95886) and nerve conduction studies (95909) provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0202U) provided October 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT code 0202U is a non-covered code. 
 
We looked at the file and Medicare rules. The code billed is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (0202U) provided October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for travel allowance (P9604). 
 
You asked the Plan to pay for the travel allowance. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the billed services. 
 
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 P9604 is Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from homebound or nursing home bound patient; 
prorated trip charge. 
 
We find that CPT code P9604 is not supported in the medical record. Specifically, insufficient records were 
provided to support this charge. There was no documentation of starting or ending mileage. Based on this 
information, we decided that Medicare rules for coverage of the travel allowance have not been met. Therefore, 
we decided that the Plan does not have to pay for travel allowance (P9604).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you received oral medications and 
had stable vital signs. You were at an independent to supervision level with bed mobility, wheelchair mobility 
and transfers. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity 
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. 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. 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 at the current level of function, the enrollee's rehabilitation can be safely provided at a lower intensity and alternate setting in a skilled nursing facility or in-home with services. Documentation 
does not support the necessity for admission to 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (CPT code 99212) provided on November 1, 
2021. 
 
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99212 
is a column II code to column I code 00811. 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 the office visit (CPT code 99212) provided on November 1, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurology services provided to the enrollee on November 1, 
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 the procedure codes are 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 the denied codes is: 
 
CPT 95885: 
 
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) 
 
 CPT 95908: 
 
Nerve conduction studies; 3-4 studies 
 
CPT 95955: 
 
Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
 
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 documentation does not support 
CPT 95885. This procedure is done with nerve conduction studies per CPT code description. In this case, nerve 
conduction studies cannot be verified, and therefore this procedure would not be covered. The documentation 
does not support CPT 95908. The technical report describes pedicle screw stimulation was performed, and 
reported as nerve conduction studies. This is incorrect reporting, as nerve conduction studies measure 
conduction, amplitude and latency/velocity. Pedicle screw stimulation would not be reported for nerve 
conduction studies, therefore this procedure code cannot be verified, as nerve conduction studies are not 
documented. The documentation does not support CPT 95955. The documentation does not support EEG 
during non-intracranial surgery (eg, carotid surgery), as the report documents "free running EMG was 
performed". Any additional testing would be inclusive to the primary neuromonitoring procedure.  
 
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 neurology services provided to the enrollee on November 1, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 13, 2021, to May 
15, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary and reasonable and should be covered as billed. The Plan denied your request. The Plan says that the 
documentation does not show that the enrollee, who had a lower gastrointestinal (GI) bleed, received 1 liter or 
more of IV fluids or a blood product transfusion prior to the decision to admit. Therefore, these services were 
not medically necessary and could have been provided as outpatient observation 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 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 enrollee presented to the emergency department (ED) on May 13, 2021, with a 
complaint of rectal bleeding with chronic lightheadedness over the last three weeks. The enrollee denies any 
other symptoms. The enrollee has a complex medical history, and the documented physical exam showed the 
rectal exam with frank red blood with minimal stool. According to the emergency room physician, the enrollee 
was hemodynamically stable and afebrile. The case was discussed with general surgery who advised admission 
for consultation. The review indicates that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollees 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 the acute inpatient hospital care provided from May 13, 2021, to May 15, 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.