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 the services are medically necessary for the 
enrollee's medial needs. The Plan denied your request. The Plan says the services the enrollee needs can be 
provided in another setting, such as a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 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 an oxygen concentrator. 
 
You asked the Plan to pre-approve the oxygen concentrator. You say that you believe that this is medically 
necessary for you. The Plan denied your request. The Plan says this equipment was not ordered by a treating 
provider and cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that oxygen may be considered reasonable and 
necessary when your treating provider has ordered blood gas testing and submitted a SWO for oxygen 
supplementation. 
 
In this case, your provider has not ordered oxygen equipment after the blood oxygen testing. Therefore, we 
decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 10, 2022 to 
September 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid. 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 August 10, 2022 to 
September 6, 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 the services are medically necessary for 
the enrollee to have the best chance for recovery. The Plan denied your request. The Plan says the enrollee's 
care can be provided in the current inpatient 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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The review indicates that 
the enrollee does not require services at the LTACH that are not available at the acute care hospital where they 
are currently receiving 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services (CPT code(s): 95937, 95886, 95909 and 
95955) provided on April 7, 2022. 
 
You asked the Plan to pay for the testing services. You say that these services are supported in the medical 
records. The Plan denied your request. The Plan says these services are not supported 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, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method, 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), code 95909 is nerve conduction studies; 5-6 studies 
and code 95955 is 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 testing services. Our reviewer found code 95937 - The 
documentation submitted was reviewed and does not meet criteria. The procedure report describes TO4 testing, 
which would not be reported with neuromuscular junction testing. No CPT code exists for TO4 as it is 
inclusive to the primary neuromonitoring procedure. Code 95886 - The documentation submitted was reviewed 
and does not meet criteria. Per CPT code description, "done with nerve conduction", and in this case nerve 
conduction studies cannot be verified as performed. Therefore, this procedure cannot be verified as performed. 
Code 95909 - The documentation submitted was reviewed and does not meet criteria. The procedure report 
does not include documentation of nerve conduction studies which measure amplitude and latency/velocity.  
The procedure report describes, "Pedicle screw stimulation", which would not be reported with nerve 
conduction studies. Code 95955 - The documentation submitted was reviewed and does not meet criteria. The 
procedure report does not include documentation of EEG during nonintracranial surgery. Our reviewer was 
unable to cite report as this procedure was not documented. Of note, any addition EEG performed would be 
included in the primary neuromonitoring service. 
 
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 (CPT code(s): 95937, 95886, 95909 and 95955) provided on April 7, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (CPT code(s): 49904 and 64746) 
provided on September 9, 2022. 
 
You asked the Plan to pay for the surgical 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. 
 
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 is omental flap, extra-abdominal (eg, for reconstruction 
of sternal and chest wall defects) and code 64746 is transection or avulsion of; phrenic nerve. 
 
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 surgical services. Our reviewer found code 49904 - The 
documentation submitted was reviewed and does not meet criteria. The operative report does not include 
enough documentation to confirm required criteria for omental flap: description of dissection of omentum from 
the stomach and the transvers colon; description of division and ligation of vessels and mobilization and 
creation of the right or left gastroepiploic vascular pedicle; description of suture fixation. The operative report 
documents, "The greater curvature was mobilized, but also a swath of the omentum based on perforators from 
the right gastroepiploic artery was preserved for tissue transfer of the omentum from the abdomen to the 
chest...the omentum was transferred in the chest and rapped around the anastomosis and the gastric staple line". 
Therefore, this procedure cannot be verified. 
 
Code 64746 - The documentation submitted was reviewed and does not meet criteria. The operative report does 
not include documentation of transection or avulsion of; phrenic nerve. The operative report documents "The 
vagus nerve was transected". Per NCCI Policy, "physician transects or removes a portion of the phrenic nerve. 
The phrenic nerve supplies innervation to the diaphragm. The physician makes a horizontal neck incision and 
dissects the surrounding tissue and locates the nerve. The nerve is transected, and the proximal portion of the 
nerve is buried in the surrounding tissue to prevent neuroma formation". Therefore, this procedure cannot be 
verified. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services (CPT code(s): 49904 and 64746) provided on September 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this claim should be paid. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on June 23, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower handrails. 
 
You asked the Plan to pre-approve a shower handrails. You say that the services are necessary. The Plan denied 
your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower handrails.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home health care services to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home health care services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that transfer to the LTACH is clinically 
appropriate in terms of type of care, frequency, extent, site, and duration for the enrollee's illness. The Plan 
denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute 
care 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cystourethroscopy (52204-59-GC) provided on February 
23, 2022.  
You asked the Plan to pay for the cystourethroscopy. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not supported by the records. 
 
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 52204 is cystourethroscopy, with biopsy(s). 
 
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 cystourethroscopy. Our reviewer found the 
documentation submitted was reviewed and does not meet criteria. The operative report documents, 
Specimens: Specimens Obtained: bladder tumor". In this case, the operative report describes one specimen, 
which would be reported with CPT 52240, and CPT 52204 would be inclusive to the primary procedure, CPT 
52240. 
 
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 cystourethroscopy have not been met. Therefore, we decided that the Plan 
does not have to pay for the cystourethroscopy (52204-59-GC) provided on February 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from acute rehabilitation 
to optimize their level of functioning prior to returning home. The Plan denied your request. The Plan says 
based on Medicare guidelines and the information we have about our condition; the enrollee does not meet all 
the requirements for an inpatient rehabilitation facility (IRF) admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from May 5, 2021, 
through May 24, 2021. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. There is a RAP claim 
submitted after 59 days of services as per the home health guidelines, i.e., the RAP claim was submitted with 
the from and through dates May 05, 2021, through May 24, 2021. Therefore, we find the Medicare rule for 
payment of this May 05, 2021, through May 24, 2021, claim has not been met and could not be processed for 
payment. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
May 5, 2021, through May 24, 2021.
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 medically necessary for the enrollee 
to return home with family assistance. The Plan denied your request. The Plan says the enrollee's needs can be 
safely fulfilled at the present facility until they are ready to transfer to lower level of care. 
 
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 clinical documentation shows that the enrollee has complex functional impairments 
however the enrollee is documented as medically stable in a skilled nursing facility. The enrollee would not be expected to require an acute hospital stay with an interdisciplinary approach to rehabilitation care. IRF criteria 
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 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 pre-approve percutaneous implantation of neurostimulator electrode 
array (CPT code 63650), and implantable neurostimulator electrode (L8680). 
 
You asked the Plan to pre-approve the services. You say that the enrollee needs these services. The Plan denied 
your request. The Plan says the requested services are not 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 services. Our physician reviewer 
found there is no documentation of psychological evaluation as required by the NCD. Therefore, at this time, 
the request is deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array (CPT code 63650), and 
implantable neurostimulator electrode (L8680).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound (76641) provided on July 12, 2022. 
 
You asked the Plan to pay for the breast ultrasound. You say that the claim should be paid. The Plan denied 
your request. The Plan says CPT code 76641 was not billed in accordance with Medicare National Correct 
Coding Initiative Policy Medically Unlikely Edits (MUE). 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the breast ultrasound have not been met. CPT code 76641 is not 
billed in accordance with Medicare National Correct Coding Initiative Policy. Medically Unlikely Edits 
(MUE). This is not a medical necessity denial. CPT code 76641 has an MUE value of 1, but billed 2 units. 
Therefore, we decided that the Plan does not have to pay for the breast ultrasound (76641) provided on July 12, 
2022.