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

We decided that the Plan does not have to pay for needle electromyography studies of anal or urethral sphincter
(51785) and needle electromyography of 2 extremities (95861) provided on March 27, 2021.
You asked the Plan to pay for needle electromyography studies of anal or urethral sphincter and needle
electromyography of 2 extremities. You say that the services at issue were a medical necessity for the enrollee.
The Plan denied your request. The Plan says the provided records do not support the services 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, the CPT Code Manual definition of code 51785 is "Needle electromyography studies (EMG) of
anal or urethral sphincter, any technique." The CPT Code Manual definition of code 95861 is "Needle
electromyography; 2 extremities with or without related paraspinal areas."
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 needle electromyography studies of anal or urethral sphincter
and needle electromyography of 2 extremities. Our reviewer says that the services at issue do not meet criteria
for payment. Our reviewer found that, with regard to CPT 51785, the procedure report does not describe a pad
or needle placed in the anal or urethral sphincter to measure electrical activity with the bladder filled and
during emptying. The operative report does not include enough detail to confirm the description of this
procedure. With regard to CPT 95861, the procedure report does not describe recordings amplified and heard
through a loudspeaker during needle insertion; these are done when no nerve conduction studies are performed
in conjunction. The operative report does not include enough detail to confirm this procedure has been
performed.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of needle electromyography studies of anal or urethral sphincter and needle
electromyography of 2 extremities have not been met. Therefore, we decided that the Plan does not have to pay
for needle electromyography studies of anal or urethral sphincter (51785) and needle electromyography of 2
extremities (95861) provided on March 27, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a kidney transplant (50360).
You asked the Plan to pre-approve the kidney transplant. The Plan denied your request. The Plan says that your
diabetes is not under control, and you are overweight. The Plan also says that you should be at a healthy weight
to get a transplant, a Body Mass Index (BMI) of 35 or less.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it 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 pre-approve the kidney transplant. Our reviewer
says that the requested items/services are considered medically reasonable and necessary in this case. Our
physician reviewer found you have end stage renal disease, poorly controlled complicated diabetes, and obesity
and have been referred for a renal transplant. Our reviewer found that different transplant centers have their
own cut-off limit for Body Mass Index (BMI) and transplant. Typical cut-off is 40 with some providing
transplant up to 42. Our reviewer also found that you meet standard criteria for the transplant, and ultimately
the decision as to whether you are appropriate comes from the transplant center.
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 kidney transplant have been met. Therefore, we decided that the Plan has to
pre-approve a kidney transplant (50360).
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 lab services (80157, 80177, 80201, 80162, 80159, 80173) provided March 25, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does 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. 

We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the billed codes are for blood sampling procedures, however the lab requisition states a urine sample was obtained. 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 (80157, 80177, 80201, 80162, 80159, 80173) provided March 25, 2021.
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 records provided support the need for the requested home ventilator. The Plan denied your request. The Plan says there are other respiratory assist devices that are capable of delivering the breathing help that the doctor has ordered. The Plan says that the enrollee is approved for bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) if requested by her doctor.  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 criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically necessary. The enrollee was hospitalized a few months ago with acute hypoxic and hypercarbic respiratory failure secondary to pneumonia and obesity-hypoventilation syndrome. There is a listed diagnosis of chronic obstructive pulmonary disease (COPD), but there are no pulmonary function tests to confirm. Nocturnal BiPAP is the appropriate treatment for obesity hypoventilation syndrome (OHS.) There is no evidence that BiPAP has been tried at home.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-covered chiropractic services (97012 and 97124) provided on August 17, 2021.  You asked the Plan to pay for codes 97012 and 97124. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says codes 97012 and 97124 are not covered when billed by a chiropractor. The Plan says that the correct copayment for code 98941, which is a Medicare-covered chiropractic code, was applied for the August 17, 2021, date of service.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue, codes 97012 and 97124, are not manual manipulation of the spine. The file shows that you have been asked to pay a $39.69 copayment for code 98941, a Medicare-covered chiropractic service, which is less than the contracted $65 copayment for out-of-network chiropractic services. Therefore, we decided that the Plan does not have to pay for the non-covered chiropractic services (97012 and 97124) provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a diagnostic consultation (D9310), and a pulp vitality test (D0460) provided by participating providers on October 5, 2021, and October 18, 2021.
You asked the Plan to pay for a limited oral evaluation, a diagnostic consultation, and a pulp vitality test. You say that these services were medically necessary. The Plan denied your request. The Plan says the benefit limit for a limited oral evaluation has already been exhausted. The Plan says that a diagnostic consultation and a pulp vitality test are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a limited oral evaluation two times during a calendar year. A diagnostic consultation and a pulp vitality test are not covered dental services.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been exhausted. Evidence was provided to show that D0140 was provided on February 22, 2021, and August 30, 2021. A diagnostic consultation and a pulp vitality test are not covered dental benefits. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), a diagnostic consultation (D9310), and a pulp vitality test (D0460) provided by participating providers on October 5, 2021, and October 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee needs to start therapy because
a delay in therapy is a delay in treatment. The Plan denied your request. The Plan says the enrollee does not
require daily skilled nursing services such as the administration of intravenous antibiotics, management and
education of a new percutaneous endoscopic gastrostomy (PEG) tube or colostomy, or complex wound care.
The Plan also says that at the current level of function, the enrollee does not require daily skilled therapy
services on an inpatient basis.
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 the SNF admission. Our reviewer says
that the enrollee does not meet the Medicare criteria for SNF care. 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 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 the SNF admission have not been met. Therefore, we decided that the Plan does
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF)
services.
You asked the Plan to pre-approve the continuation of SNF care. You say that the records provided support the
need for continued SNF care. You say that you are still unable to walk and have large wounds on the calf and
foot which has complicated rehabilitation. The Plan denied your request. The Plan says the enrollee does not
meet the requirements for coverage of SNF care. The Plan says that the enrollee no longer requires daily skilled
services and continued SNF care is not medically necessary.
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 the continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not
have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Skilled
services are not shown to be required to establish a maintenance program or to prevent deterioration of the
enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care.
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 continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a U step walker for the enrollee.
You asked the Plan to pre-approve a U step walker. You say that this walker would provide him better support
and stability. The Plan denied your request. The Plan says that duplicate equipment is not a covered benefit.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have a walker. A walker serves the same purpose as a U step walker. Therefore, we
decided that the Plan does not have to pre-approve a U step walker for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services received August
20, 2021 to August 25, 2021.
You asked the Plan to pay for the SNF services. You say that you disagree with the plan's denial. The Plan
denied your request. The Plan says the services exceeded the enrollee's benefit limit.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from June 23, 2021.
The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pay for the skilled nursing facility (SNF) services received August 20, 2021 to
August 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 8, 2021.
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 70450 may be eligible for payment when billed with CPT code 70496. The provided claim does not show that CPT code 70450 was billed with a modifier which allows separate payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lidocaine patch.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 lidocaine patch.
Benefits for self-administered drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99204 provided on September 1, 2021.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 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. In this case, the CPT Code Manual definition of code 99204 is office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
We find that CPT code 99204 is not supported in the medical record. Specifically, this service was billed with a place of service of 23 (emergency room- hospital). This code is used to report evaluation and management services provided on the office or in an outpatient or other ambulatory facility. Medical records show the enrollee was seen for an Emergency Department visit. Therefore, this is not the appropriate procedure code to be billed for the services actually rendered. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99204 provided on September 1, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care
provided from January 15, 2020, to January 23, 2020.
You asked the Plan to pay an additional amount for the inpatient care. You say that the diagnosis codes are
supported. The Plan denied your request. The Plan says the provided documentation does not support the
primary and secondary diagnosis codes, A41.9 and G93.41.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with primary diagnosis code, A41.3, defined as Sepsis,
unspecified organism, and secondary diagnosis code, G93.41, defined as Metabolic encephalopathy. 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 an additional amount for the inpatient care. Our reviewer
says that the primary and secondary diagnoses codes are not supported. Our physician reviewer found the
provided documentation does not indicate there was evidence of a rise in SOFA of 2 or more points that cannot
be easily explained by causes other than sepsis. The reviewer found that the provided documentation does not
indicate the enrollee is showing evidence of significant physiologic instability. The reviewer found that the
provided documentation does not support the condition treated as consistent with a systemic infectious process.
Therefore, the reviewer found that the billing of the primary and secondary diagnoses codes are not supported.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
an additional amount for the acute inpatient hospital care provided from January 15, 2020, to January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 00630 provided on July 22,
2021.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed 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.
In this case, the CPT Code Manual definition of code 00630 is anesthesia for procedures in lumbar region; not
otherwise specified.
We find that CPT code 00630 is not supported in the medical record. Specifically, the documentation shows
that this anesthesia code was reported with code 64561 (Percutaneous implantation of neurostimulator
electrode array; sacral nerve (transforaminal placement) including image guidance, if performed). A claim that
includes a surgery/procedure is not found that appropriately crosswalks to the anesthesia code. A surgical code
that appropriately crosswalks to the anesthesia services must be reported to support the anesthesia code. Based
on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met.
Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00630 provided on
July 22, 2021.