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 rendered from August 
2, 2022, to August 26, 2022. 
 
You asked the Plan to pay for the services. You say that you submitted supporting documentation for 
reconsideration of the adjustment. The Plan denied your request. The Plan says the records do not support the 
services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our reviewer to carefully review the case file and apply the relevant Medicare rules to determine if 
the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that the records do not support a 
physical therapy/occupational therapy (PT/OT function score of 10-23. No SNF PT/OT records have been 
identified in the case file. The records do not support that the enrollee received special care high for an active 
diagnosis of septicemia.  There is no evidence that the enrollee had active septicemia. The records do not 
support that the enrollee received IV medications. While it appears that the enrollee was supposed to receive IV 
antibiotics upon discharge, there is no evidence that IV antibiotics were ordered or provided during the initial 
days at the SNF. 
 
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 skilled nursing facility (SNF) services rendered from August 2, 2022, to August 26, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services described by code 99316 
performed on date of service April 7, 2023. 
 
You asked the Plan to pay for 99316. You say that 99316 should be paid as billed because it is supported in the 
documentation and was separate from any other encounter. The Plan denied your request. The Plan says that 
99316 is denied because this service is included in global surgical package for code 45915. 
 
The Plan must follow Medicare rules. Medicare rules say that that physicians in the same group practice but 
who are in different specialties may bill and be paid without regard to their membership in the same group. The 
rules also say that services of other physicians are not included in the global surgical package except when the 
surgeon and the other physician(s) agree on the transfer of care. 
 
We looked at the file and Medicare rules. In this case, we confirmed that procedure code 45915 performed on 
March 29, 2023, has a global surgery indicator of 010. As such, 99316 billed for date of service April 7, 2023, 
was performed during the postoperative period of code 45915. But we also confirmed that while the provider 
who performed 45915 does bill under the same group practice as the provider who performed 99316 on April 
7, 2023, these two providers do not have the same specialty and have different taxonomy codes. Per Medicare 
rules, physicians in the same group practice but who are in different specialties may bill and be paid without 
regard to their membership in the same group. Also, services provided by other physicians are not included in 
the global surgery package of a procedure unless the surgeon and other physican agree on a transfer of care. 
There is no evidence in the case file of a transfer of care. Based on this information, we decided that Medicare 
rules for coverage of 99316 have been met. Therefore, we decided that the Plan has to pay for the evaluation 
and management services described by code 99316 performed on date of service April 7, 2023.  
 
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 the definitive drug testing provided on June 27, 2023, billed with code 
G0481.  
 
You asked the Plan to pay for the drug testing as billed. You say that this was medically necessary drug testing. 
The Plan denied your request. The Plan says that the documentation submitted did not include documentation 
of the method of testing used to support the code billed. 
 
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 We find that the Plan's denial rationale is not supported. While the 
code definition does mention several of the testing methodologies described under the code, this does not 
appear to require that the specific methodology for each drug analyte be described on the lab report. The 
definition just appears to indicate all of the testing types that are reimbursed under this code. The records do 
support that definitive (quantitative) drug testing was performed as described by this code. Without a valid 
rationale, the denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for the 
definitive drug testing provided on June 27, 2023, billed with code G0481.   
 
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 pre-approve out-of-network (OON) chiropractic care at the Midwest 
Spine and Nerve Center. 
 
You asked the Plan to pre-approve the OON chiropractic care. You say that you believe that you should be 
allowed to go to this provider because you have tried so many different medications, and you are not able to 
use devices because of your pacemaker. You state that you are desperate for help for your condition. The Plan 
denied your request. The Plan says you have not been seen by any in-network chiropractic providers at this 
time. Referral for OON services would only be allowed if a network chiropractor treated you and made a 
referral to this provider. Since there is no network deficiency, this OON is not required currently. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is 
not providing these services and is not making arrangements to provide these services. Therefore, we decided 
that the Plan does not have to pre-approve out-of-network (OON) chiropractic care at the Midwest Spine and 
Nerve Center.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the post stabilization care provided from June 22, 2023, to 
June 27, 2023, by an out-of-network provider. 
 
You asked the Plan to pay for the post stabilization care. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says the post stabilization care was not 
medically necessary as the enrollee was stabilized in the emergency department. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that the post stabilization care was not medically necessary at the out-of-network facility. Our physician 
reviewer found the enrollee appeared to be stable for transfer to a Plan facility after her assessment in the 
emergency department. She had evidence of biliary obstruction with jaundice, but no sign of cholangitis or any 
other condition that would have precluded a transfer. There are no physician notes to indicate that the enrollee 
was not stable for transfer. The documentation suggests that the enrollee was stable for transfer on June 22, 
2023, after a computed tomography scan of the abdomen was performed. 
 
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 post stabilization care have not been met. Therefore, we decided that the 
Plan does not have to pay for the post stabilization care provided from June 22, 2023, to June 27, 2023, by an 
out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86300 billed for July 19, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare policy prohibits separate payment for 
duplicate testing or testing for the same analyte by more than one methodology. 
 
We looked at the file and Medicare rules. The file shows that procedure code 86300 was previously paid by the 
Plan for the same date of service by a different provider. 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 
pay for procedure code 86300 billed for July 19, 2023.
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 LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has 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 appears to be unstable with current treatment and requires additional 
acute care hospital services that can safely be provided at the current facility until more stable and appropriate 
for transfer. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility.  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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service June 20, 
2023. 
 
You asked the Plan to pay for procedure code 93971. You say that the code is payable with the modifier. The 
Plan denied your request. The Plan says payment for code 93971 is bundled into payment for code 36465. 
 
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 93971 is a column II code to column I code 36465. Code 93971 was 
billed with a -59 modifier. The medical records do not show that the service billed with the -59 modifier was a 
distinct procedural service. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 93971 billed for date of service 
June 20, 2023.
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. The Plan denied your request. The Plan says the home 
noninvasive ventilator requested does not meet the requirements for approval. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the patient was noncompliant 
with BIPAP and does not have documented failure of BIPAP. Our reviewer also found that the patient does not 
meet criteria, as best practice, per the documentation for a home ventilator 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 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external electrocardiographic recording (93246, 
93248). 
 
You asked the Plan to pre-approve an external electrocardiographic recording. You say that the enrollee has 
Holter monitoring done every year. You also say that all of the information needed, as well as an 
electrocardiogram were submitted. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria as they are asymptomatic and there is no change in anti-arrhythmic drug therapy. 
 
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 an external electrocardiographic 
recording. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has had no new signs, symptoms, or clinical 
changes since the last recording. In summary, there is insufficient documentation to support the medical 
necessity for repeat external electrocardiographic recording in this enrollee's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an external electrocardiographic recording have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an external electrocardiographic recording (93246, 93248).
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. You say that the SNF services requested are medically necessary. 
The Plan denied your request. The Plan says the SNF services requested do not meet the requirements for 
approval. 
 
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 clinical documentation shows that your past level of function was modified 
independent with mobility tasks and required assist with activities of daily living (ADLs); currently requiring 
supervision with functional mobility and self-care tasks thus appropriate daily inpatient skilled therapy goals 
have been met. The documentation does not specify any daily skilled nursing needs thus daily skilled services 
are not supported. As a practical matter, clinical documentation does not justify continued daily skilled services 
on an inpatient basis in a skilled nursing facility. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95923-59 provided February 24, 2023. 
 
You asked the Plan to pay for the service. 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 95923 is testing of autonomic nervous system function; 
sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic 
sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential. 
 
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 service. Our reviewer found the documentation submitted was reviewed and does not meet criteria. For CPT 95923, the provider tests the sudomotor function of the 
autonomic nervous system to check functioning of nerves that supply sweat glands. The autonomic nervous 
system is that part of the nervous system that controls the blood pressure, pulse rate, sweating, and many other 
bodily functions. This procedure was not included in documentation submitted and cannot be verified as 
performed. Our coder was unable to cite report, as this procedure was not found. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95923-59 provided February 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the tubing, the face masks, and the head 
gear provided on September 25, 2023. 
 
You asked the Plan to reduce the coinsurance for the tubing, the face masks, and the head gear. You say that 
you have been charged too much. 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 20% 
coinsurance for in-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the tubing, the face masks, and the head gear. This 
item/service falls within the in-network durable medical equipment and related supplies 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 reduce the coinsurance for the tubing, the face masks, and the head gear provided on 
September 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 25, 2023, by an OON 
provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on April 25, 2023, by an 
OON provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 61580-62 billed for date of service July 25, 2023. 
 
You asked the Plan to pay for the billed service. You say that the enrollee was treated in good faith. The Plan 
denied your request. The Plan says that an assistant at surgery is not payable for this service. 
 
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 61580-62 is supported. The service at issue was provided by a co-surgeon. Neither the 
claim, nor the medical records indicate that an assistant at surgery service was provided. Based on this 
information, we decided that Medicare rules for coverage of the billed service have been met. Therefore, we 
decided that the Plan has to pay for procedure code 61580-62 billed for date of service July 25, 2023.  
 
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.