Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
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 procedure is medically reasonable 
and necessary to solve the enrollee's chronic low back pain. The Plan denied your request. The Plan says the 
request 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 requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of pain is not clear. There is no magnetic resonance imaging (MRI) 
showing only Modic changes without facet degenerative joint disease or stenosis. 
 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit provided on 
June 06, 2023. 
 
You asked the Plan to waive the copayment for an emergency department visit. You say that you left the 
emergency department after a long wait time. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an emergency department visit. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency 
department visit provided on June 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orion skin substitute. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have 
lymphedema (swelling) of the legs and chronic wounds. The requested Orion skin substitute does not have 
enough data supporting its effectiveness and is not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Orion skin substitute.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on July 3, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the enrollee was evaluated in the emergency department (ED) for ongoing leg pain, in the setting of known 
mild rhabdomyolysis. The records support an appropriate history and physical were obtained; However, the 
medical decision making was not of high complexity. As such, the billing of CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on July 3, 2023.
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 you would like to initiate an expedited appeal 
regarding the acute inpatient rehabilitation denial for the patient. The Plan denied your request. The Plan says 
based on Medicare guidelines, 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 the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer found that while the medical record supports a need 
for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. Our physician reviewer also found that 
there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit (procedure 99285) provided 
on July 6, 2023. 
 
You asked the Plan to pay for an emergency department visit (procedure 99285). You say that procedure code 
99285 is appropriate based on the services performed. The Plan denied your request. The Plan says the records 
do not support the services at issue in this case. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency department visit (procedure 99285). Our 
reviewer says that the service at issue in this case is not supported by the medical records. Our reviewer found 
the enrollee was evaluated in the emergency department (ED) for chest pain following a recent cardiac 
catheterization. The records support an appropriate history and physical were obtained; However, a standard 
evaluation was performed, and the medical decision making was not of high complexity. As such, the billing of 
CPT 99285 is not supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency department visit (procedure 99285) have not been met. 
Therefore, we decided that the Plan does not have to pay for an emergency department visit (procedure 99285) 
provided on July 6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospitalization provided from July 18, 2023, to 
July 20, 2023. 
 You asked the Plan to pay for the inpatient hospitalization. You say that the inpatient stay was medically 
necessary at the acute level of care. You also say that you are requesting the denial be overturned and the 
payment for inpatient treatment rendered appropriately as per the expected reimbursement. The Plan denied 
your request. The Plan says the available medical records do not support medical necessity for inpatient 
admission for the diagnosis of Acute Coronary Syndrome. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient hospitalization. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the patient presented to the emergency department with chest pain. An 
electrocardiogram showed no acute findings, troponins negative, chest x-ray normal, computed tomography 
ruled out pulmonary embolism, echocardiogram showed normal ejection fraction, and stress test normal ruling 
out significant acute conditions. Our reviewer found that the patient's vitals remained stable. The patient was 
admitted and discharged 2 days later. However, at the time of admission, based on initial testing results and 
clinically stable presentation, it was not expected that the patient would have an adverse event or require 
hospital services that would likely have crossed 2 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 the inpatient hospitalization have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospitalization provided from July 18, 2023, to July 20, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient admission provided on August 15, 2021. 
 
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says that the 
information received does not support that criterion were met for inpatient hospitalization and the original 
denial is upheld. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the inpatient admission. Our reviewer says 
that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was evaluated in the emergency department with a history and physical exam, 
blood work, electrocardiogram, chest x-ray, and venous dopplers. The enrollee was started on intravenous 
antibiotics and admitted with a diagnosis of chest pain and elevated troponin. Our reviewer found that the 
enrollee's condition stabilized and improved, and they were discharged home when considered medically stable 
on August 17, 2021. Our physician reviewer also found that the record showed that at the time of inpatient 
admission it was reasonable for the admitting physician to expect that the enrollee's necessary hospital care 
(including earlier emergency department and/or observation care) would span two midnights with supporting 
documentation of the enrollee's history and comorbidities, signs and symptoms, current medical needs, and risk 
of an adverse event. 
 
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 inpatient admission have been met. Therefore, we decided that the Plan has 
to pay for the inpatient admission provided on August 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.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 testing provided on November 21, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that the correct diagnosis was billed. You also say 
that the testing was down during the public health emergency. The Plan denied your request. The Plan says that 
tests that are considered non-diagnostic are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the case file supports that the services were billed with diagnosis 
code Z20.822 representing Contact with and (suspected) exposure to COVID-19. The Plan has not supplied any 
records or evidence to support that the services in dispute were non-diagnostic and has not substantiated their 
denial reason. Therefore, we decided that the Plan has to pay for the COVID-19 testing provided on November 
21, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 98960 billed for date of service July 11, 
2023. 
 
You asked the Plan to pay for procedure code 98960. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 98960 is considered bundled and 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 procedure code. 
 
We find that procedure code 98960 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 98960 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 98960 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 98960 billed for date of service July 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 5, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was initially submitted 
to Original Medicare and it was rejected. 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 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87077, 87150, 87481, 87640, 87653 and 
87798 billed for date of service July 17, 2022. 
 
You asked the Plan to pay for procedure codes 87077, 87150, 87481, 87640, 87653 and 87798. You say that 
these services were necessary and are supported in the medical record. The Plan denied your request. The Plan 
says these codes 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, we have confirmed that codes 87481, 87640, 87653 and 87798 are column II codes to column I 
code 87150; however, 87481, 87640, 87653 and 87798 were each billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87077, 87150, 87481, 87640, 87653 and 
87798. Our reviewer says that these codes are not supported as billed. Our reviewer found that the laboratory 
report does not include documentation to support culture bacterial; aerobic isolate, additional methods required 
for definitive identification, each isolate (code 87077). This procedure was not found in medical record and 
therefore cannot be verified. The laboratory report also does not include documentation of culture typing (code 
87150); therefore, this code cannot be verified. In addition, codes 87481, 87640, 87653 and 87798 would be 
included in code 87150 when reported correctly; the records provided do not support the use of the XU 
modifier to report these codes separately. 
 
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 87077, 87150, 87481, 87640, 87653 and 87798 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 87077, 87150, 87481, 
87640, 87653 and 87798 billed for date of service July 17, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve echocardiography services. 
 
You asked the Plan to pre-approve echocardiography services. You say that the enrollee has peripheral arterial 
disease status post angioplasty, atherectomy and stent placement. The Plan denied your request. The Plan says 
that the enrollee has no new signs of coronary ischemia, no new signs concerning for vascular heart disease, 
and no signs attributed to congestive heart failure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not provide any medical records for the enrollee 
involved in this case. Without this information we cannot evaluate whether Medicare criteria for coverage have 
been met, and the Plan has not substantiated their denial reason. Therefore, we decided that the Plan has to pre-
approve echocardiography services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95822 and 95999 billed for date of service 
October 17, 2022. 
 
You asked the Plan to pay for the billed services. You say that intraoperative neuromonitoring reduces the risk 
of deficits. The Plan denied your request. The Plan says the billed codes are not supported. 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 95822 is electroencephalogram (EEG); recording in coma 
or sleep only. We find that CPT code 95822 is not supported. The records do not show that the testing at issue 
was provided during coma or sleep.  
 
We find that CPT code 95999 was billed for train of four testing. Train of Four testing is bundled with the 
intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials (MEP) and not 
separately reportable. Based on this information, we decided that Medicare rules for coverage of the billed 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
95822 and 95999 billed for date of service October 17, 2022.