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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from January 
4, 2022, to January 16, 2022, as billed with rate code KDSD1. 
 
You asked the Plan to pay for SNF care billed with rate code KDSD1. You say that this care was medically 
necessary, and all services/conditions were reported correctly. The Plan denied your request. The Plan says the 
reported PDPM code is not supported for the care provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report SNF services with the appropriate HIPPS code. 
 
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 SNF care billed with rate code KDSD1. Our 
reviewer says that the submitted PDPM code is not supported in this case. Our physician reviewer found that 
there is no indication that the member has an active diagnosis of malnutrition or that her functional level was 
appropriately documented. The 1st and the 4th alphanumeric character in the PDPM were not correct. The 
partial adjustment to PDPM LDSE1 was 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 SNF care billed with rate code KDSD1 have not been met. Therefore, we 
decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from January 4, 
2022, to January 16, 2022, as billed with rate code KDSD1.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a home 
ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says that the enrollee does not meet criteria for a home ventilator. Our physician reviewer found the enrollee has a 
diagnosis of chronic obstructive pulmonary disease (COPD) and congestive heart failure and was admitted in 
February 2022 with a heart failure exacerbation. Arterial blood gas (ABG) reportedly showed CO2 retention, 
and the enrollee was discharged on a home ventilator. The appeal letter indicates the enrollee had a normal 
PCO2 on July 8, 2022, although that report is not provided. A compliance report covering March 8, 2022, to 
February 24, 2022, shows that the device was used for at least 4 hours/day on only 4% of days. This does not 
meet minimum Medicare use criteria and is insufficient use for effectiveness. In addition, Medicare does not 
cover a home ventilator when used at settings that can be provided with bilevel positive airway pressure 
(BiPAP). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure 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 pre-approve the Intracept procedure. Our reviewer 
says that the Intracept procedure is not medically necessary. Our physician reviewer found the magnetic 
resonance imaging (MRI) shows foraminal stenosis. The cause of back pain is not clear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93355 and 99100 billed for date of service 
August 6, 2021. 
 
You asked the Plan to pay for procedure codes 93355 and 99100. The Plan denied your request. The Plan says 
payment for codes 93355 and 99100 is bundled. 
 
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 93355 
is a column II code to column I code 01926. 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. 
 
We also find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means 
that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules 
for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 93355 and 99100 billed for date of service August 6, 2021.
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. The Plan denied your request. The Plan says based on 
guidelines and the information we have about the enrollee's condition, the requirements have not been met, 
services needed could be provided in another setting, 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 has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed 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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a transforaminal epidural steroid injection. 
 
You asked the Plan to pre-approve transforaminal epidural. You say that you need this to get back to a better 
quality of life. The Plan denied your request. The Plan says that you do not meet criteria for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that epidural steroid injections may be covered under 
certain circumstances. 
 
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 facet joint injection. Our reviewer says 
that you meet the criteria for the requested diagnostic medial branch blocks. Our physician reviewer found you 
have chronic low back pain. You have had physical therapy and your medical trials include gabapenin, flexeril, 
and a medrol dosepak. You have had a right L5-S1 transforaminal epidural steroid injection which gave 100% 
pain relief. Your pain has returned and the request is for diagnostic medial branch blocks. Imaging shows 
multi-level facet arthropathy. This request is medically reasonable and 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 facet joint injection have been met. Therefore, we decided that the Plan has to 
pre-approve a transforaminal epidural steroid injection.  
 
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: Favorable

 
We decided that the Plan has to pay for procedure codes 95886 and 95909 provided on October 13, 2022. 
 
You asked the Plan to pay for procedure codes 95886 and 95909. You say that the medical records support the 
billing of codes 95886 and 95909. The Plan denied your request. The Plan says that the medical records do not 
support the billing of codes 95886 and 95909. 
 
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 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 procedure codes 95886 and 95909. Our reviewer says that 
the medical records support the billing of codes 95886 and 95909. Our reviewer found the medical records do 
support the use of procedure code 95886 as this is an add on code that can be added to 95909. This add on code 
was supported in the documentation by the studies done on the scalp, spine, carotid, and train of four. Medical 
records also support the use of procedure code 95909 with the documentation showing the upper and lower 
extremities being tested. 
 
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 95886 and 95909 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 95886 and 95909 provided on October 13, 2022.  
 
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 pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request for a home ventilator is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that 
there is no diagnosis of COPD or neuromuscular disease.  It is unclear from the record whether the enrollee has 
thoracic restrictive disease related to the spinal fractures. There is no documentation of chronic hypercarbic 
respiratory failure with an arterial blood gas (ABG) done while stable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the IRF services requested 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 the complexity of your documented nursing, medical and rehabilitation needs would 
not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. Additionally, evaluating therapy notes do not show that you would tolerate an intensive therapy regimen. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64999) provided on October 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not payable. 
 
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 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 payment for the billed 
code is not supported by the records provided Our reviewer found that per coding guidelines, there should have 
been a note and a comparable code billed, which were not submitted with the medical records. The comparable 
code in this case would be CPT 64510. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (64999) provided on October 18, 2022.
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 you do not feel the enrollee can meet the 
standard physical therapy hours per day, and the enrollee's current condition requires telemetry and cardiac 
follow-up which cannot be handled by a skilled nursing facility (SNF). The Plan denied your request. The Plan 
says the records do not show that it is medically necessary for the enrollee to be in an LTACH in place of an 
acute care hospital. 
 
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 that all medically necessary care is being provided in the current acute care setting.  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 15-21 drug classes 
(G0482) provided on October 5, 2022. 
 
You asked the Plan to pay for definitive UDT. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the number of drug classes tested was not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when each drug class tested is 
medically necessary. 
 
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 definitive UDT. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that the use of confirmatory testing should be 
based on the need to detect specific drug metabolites that cannot be identified on standard immunoassays, or on 
the presence of unexpected presumptive urine drug test results. In addition, clinicians should not test for 
substances when the results would not affect patient management, or for which implications for patient 
management are unclear. Each individual definitive drug class tested must be medically necessary, and the 
results of each drug class tested must be used to treat an active illness or disease, as opposed to being used for 
screening purposes. There was no indication for testing 15-21 drug classes.  The request was not medically 
reasonable and 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 definitive UDT have not been met. Therefore, we decided that the Plan does not 
have to pay for definitive urine drug testing (UDT) for 15-21 drug classes (G0482) provided on October 5, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 23, 2021, 
to January 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that a NOA was not required until 
January 1, 2022, and the claim was submitted before that. The Plan denied your request. The Plan says the 
claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from December 23, 2021, to 
January 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says your records do not 
show that you meet the criteria, the intermittent services you require can safely be received at a different 
setting, in residential care where you reside as your baseline, or home with home health. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a panoramic 
radiographic imaging (D0330), extractions (D7210), and dental extractions (D7210), provided on November 
15, 2022, to December 6, 2022.  
 
You asked the Plan to pay for the dental services. You say that you had an infection, and you needed this dental 
work done. The Plan denied your request. The Plan says these services have been processed correctly. 
 
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 supplemental dental work was exhausted on December 6, 2022. Therefore, we decided that the Plan does not have to waive the copayment for a comprehensive oral evaluation (D0150), and a 
panoramic radiographic imaging (D0330), and does not have to pay for extractions (D7210), and dental 
extractions (D7210), provided on November 15, 2022, to December 6, 2022.