Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 95886, 95908, and 95955 rendered on March 28, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the 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 
the denied codes is: 
 
CPT 95886: 
 
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) 
 
CPT 95908: 
 
Nerve conduction studies; 3-4 studies 
 
CPT 95955: 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records.  
 
Our reviewer found that in terms of CPT 95886, the muscles included in the electromyography were tibialis 
anterior, medial gastrocnemius, vastus medialis, adductor longus, abductor hallucis. Therefore, the records do 
support this code. 
 
In terms of CPT 95908, the procedure report cites trigger electromyography/nerve conduction velocity, L3 and 
L4 screws bilaterally. Therefore, the records do support this code. 
 
Finally, in terms of CPT 95955, the procedure report cites electroencephalography was performed during the 
procedure. Therefore, the records do support this code. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
procedure codes 95886, 95908, and 95955 rendered on March 28, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance services provided on October 22, 2022. 
 
You asked the Plan to pay for the air ambulance services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not medically necessary.  
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the documentation does not support that the transportation to another hospital other than the closest 
was medically reasonable or necessary. Our physician reviewer found the enrollee experienced a seizure while 
driving. The enrollee was alert, some confusion, no focal neurologic deficit, and Glasgow Coma Scale 14. 
Family was in contact with Emergency Medical Services (EMS) requesting Grandview. The enrollee was 
transported from Oxford, Alabama to Grandview Medical Center, Birmingham, AL (54 ground miles) billing 
52.2 air miles. The clinical record clearly documented the enrollee was transported to a specific facility that 
was requested by the family. There is a closer hospital capable of providing care: Regional Medical Center, 
Aniston, AL (5.9 ground miles). The air ambulance transport time (31) minutes was significantly longer than 
the estimated drive time to the closest facility. There was no clear barrier to transport to the closest appropriate 
facility or use of ground ambulance transportation for this enrollee. Therefore, the documentation does not 
support that the enrollee was required to go to the hospital that they went to rather than the closer hospital. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for the air ambulance services provided on October 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) additional months of a home ventilator 
(E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee has been under your care for the 
management of her chronic respiratory failure secondary to severe COPD. She has been on a therapeutic 
treatment plan for years, including bronchodilators, steroids, oxygen therapy and noninvasive ventilatory 
support. Without NIV therapy, the enrollee is at high risk for hospital readmission and potentially life-
threatening exacerbations. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
approval of the ventilator. The device may not be used in the Bilevel-PAP mode. The device is not medically 
necessary. The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records document 
that the home ventilator is being requested for use in average volume assured pressure support (AVAPS) mode 
with auto-EPAP (AE) which could be provided by a BiPAP device with AVAPS and a back-up rate. As stated 
in the Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-level 
CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve nine (9) additional months of a home ventilator (E0466).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 88374 billed for date of service January 11, 2023. 
 
You asked the Plan to pay for procedure code 88374. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says that the payment for code 88374 is included 
in the payment for code 81450. 
 
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 has not provided a copy of the original claim as it was 
submitted for payment. Without this document, we cannot verify that these services were billed together in a 
way which conflicts with Medicare guidelines. Therefore, we decided that the Plan has to pay for procedure 
code 88374 billed for date of service January 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 10, 2022. the 
laboratory services rendered on October 10, 2022. 
 
You asked the Plan to pay for the laboratory services rendered on October 10, 2022. these services. You say 
that you disagree with the denial. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 the laboratory services rendered on 
October 10, 2022. the laboratory services rendered on October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunoassay testing billed with code 86304 for 
December 6, 2022. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that the -GA modifier is used on charges associated with 
an Advanced Beneficiary Notice (ABN) to signify non-covered charges 
 
We looked at the file and Medicare rules. The file shows that the services were billed with the -GA modifier 
and are therefore non-covered. You signed an ABN on December 6, 2022 acknowledging that you understood 
that these services would not be covered by the Plan. Therefore, we decided that the Plan does not have to pay 
for the immunoassay testing billed with code 86304 for December 6, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the ocular eye injections. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says that they denied the injection itself because whether, or not, another 
injection is needed is dependent upon the provider's examination. The Plan states the provider can decide if you 
need another injection for wet macular degeneration and if so, request a follow-up for the injection.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 medication. Our physician reviewer 
found the requested drug is not FDA approved for your diagnosis. Intravitreal Avastin (bevacizumab) is 
supported as an effective and standard of care treatment for exudative / Wet Age-Related Macular 
Degeneration. Avastin is considered an appropriate, safe, and effective treatment for exudative macular 
degeneration. 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve the ocular eye injections.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on September 2, 2022, to 
September 8, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis code A41.9, described as Sepsis, 
unspecified organism. 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 hospital 
services at the DRG originally billed. Our reviewer says that documentation does not support the billed code. 
Our physician reviewer found that the enrollee is a 71-year-old female who presented with abdominal pain, 
nausea, and vomiting. Her blood pressure and heart rate were elevated, oxygen saturation was normal on room 
air. Imaging revealed large hiatal hernia. It was revealed that the enrollee had not been taking the prescribed 
domperidone, which was restarted, helping her symptoms to resolve. The enrollee was also given fluids and 
antibiotics as well as promethazine, and pantoprazole. The records showed Creatinine 1.6 and later 1.2 after 4 
days of treatment. Glasgow Coma Scale was 15. Bilirubin and platelets were normal. There was no reported 
oliguria. Based on these findings, one SOFA point was identified, and Sepsis 3 criteria was not met. There was 
insufficient evidence to show the enrollee experienced a life-threatening dysregulated response to systemic 
infection leading to organ failure to justify the A41.9 code (sepsis).   
 
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 
for inpatient hospital services provided on September 2, 2022, to September 8, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical shoulder arthroplasty (procedure code 29823) rendered on 
October 18, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the 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 29823 is "Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, 
humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies])." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the procedure details cite the labral 
tears were debrided extensively down to the stable rim of labrum. Tearing was in the anterior, superior, and 
posterior regions. The undersurface of the rotator cuff tear was trimmed lightly in preparation for repair. The 
subacromial space was decompressed. Therefore, the records do support CPT 29823 in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical shoulder arthroplasty (procedure code 29823) rendered on October 18, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve parathyroid planar imaging. 
 
You asked the Plan to pre-approve parathyroid planar imaging. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the requested 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 parathyroid planar imaging. 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 hyperthyroidism. The enrollee was noted to have 
hoarseness, fatigue, intolerance to heat, and an enlarged thyroid on examination. There was no clinical 
indication based on the provided documentation for a parathyroid planar image study to justify this request. 
Therefore, the enrollee does not meet criteria for the requested services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of parathyroid planar imaging have not been met. Therefore, we decided that the 
Plan does not have to pre-approve parathyroid planar imaging.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 30, 2022, to 
August 3, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 principal diagnosis A41.9, described as Sepsis, 
unspecified organism. 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 hospital 
services at the DRG originally billed. Our reviewer says that documentation does not support the billed code. 
Our physician reviewer found that the enrollee is a 66-year-old female with a history of hypotension, Multiple 
sclerosis, autonomic dysfunction, who presented with abdominal pain. Imaging showed distended gallbladder 
with pericholecystic fluid. She was diagnosed with cholecystitis. She underwent surgery complicated by 
anemia and hypotension later thought to be related to medication. She required vasopressors, fluids and 
hypotension resolved. Bilirubin was normal and Creatinine 1.14 following treatment. Platelets were normal. 
She was alert and oriented without hypoxia. The provided documentation does not describe a life-threatening 
dysregulated response to systemic infection leading to organ failure. Sepsis 3 criteria is not met. Therefore, the 
code, A41.9, sepsis, is not supported for this admission.   
 
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 
for inpatient hospital services provided on July 30, 2022, to August 3, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
18, 2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) device supplies 
provided on October 21, 2022. 
 
You asked the Plan to pay for CPAP supplies. You say that the items at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. The document 
provided as proof of delivery is for a different date of service. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for continuous positive airway pressure (CPAP) device supplies provided on October 21, 2022.