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

 
We decided that the Plan does not have to pay for procedure code 93313-59 provided on December 13, 2022. 
 You asked the Plan to pay for procedure code 93313-59. You say that the medical records support the use of 
modifier 59 with code 93313. The Plan denied your request. The Plan says the medical records do not support 
the use of modifier 59 with code 93313. 
 
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 93313 is a column II code to column I code 00560; however, 93313 
was 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 code 93313-59. Our reviewer says that the medical 
records do not support the use of modifier 59 with code 93313. Our reviewer found CPT code 93313 is not 
supported. The record states that transesophageal echocardiogram (TEE) guidance was performed for the main 
procedure. This is considered guidance and not a separately reportable diagnostic procedure. Therefore, CPT 
code 93313 is not supported. The record does not support that 93313 was performed as a separately identifiable 
diagnostic procedure. 
 
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 code 93313-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93313-59 provided on December 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 13, 2021, 
through July 16, 2021, and billed with diagnosis codes A41.51 and G93.41. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that primary 
diagnosis A41.51 and secondary diagnosis G93.41 is supported by the records. The Plan denied your request. 
The Plan says the documentation submitted does not support primary diagnosis of A41.51 and secondary 
diagnosis of G93.41. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with primary diagnosis code A41.51-Sepsis due to 
Escherichia coli- [E. coli] and secondary diagnosis code G93.41-Metabolic encephalopathy. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the inpatient hospital services at the DRG originally billed. 
Our reviewer says that the documentation does not support the primary diagnosis of A41.51-Sepsis due to 
Escherichia coli- [E. coli] and secondary diagnosis of G93.41-Metabolic encephalopathy. Our physician 
reviewer found the member presented to the hospital with high blood pressure, back pain, leukocytosis. The 
member was diagnosed and treated for a urinary tract infection. Also noted in the documentation was normal 
platelets, normal bilirubin, oxygen saturation was at 95 percent on room air, and alert and oriented three times. 
There was no documented evidence of encephalopathy and no signs of organ failure to meet the definitions and 
criteria for metabolic encephalopathy or sepsis. Therefore, the documentation does not sufficiently support 
primary diagnosis code A41.51, (Sepsis due to Escherichia coli [E. coli] or secondary diagnosis code G93.41 - 
Metabolic encephalopathy.  
 
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 13, 2021, through July 16, 2021, and billed with diagnosis 
codes A41.51 and G93.41.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87899 and 87900) provided on 
November 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says these services are not supported in the medical record. 
 
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 87899 is infectious agent antigen detection by 
immunoassay with direct optical (ie, visual) observation; not otherwise specified. The definition of code 87900 is infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics. 
 
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 laboratory services. Our reviewer found for code 87899, 
the documentation submitted was reviewed and does not meet criteria. The laboratory report does not include 
sufficient documentation to confirm this procedure has been performed. Our coder was unable to cite report as 
this procedure was not found in documentation, and therefore, cannot be verified. For code 87900, the 
documentation submitted was reviewed and does not meet criteria. The laboratory report does not include 
sufficient documentation to confirm this procedure has been performed. Our coder was unable to cite report as 
this procedure was not found in documentation, and therefore, 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87899 and 87900) provided on November 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the aluminum rigid removable standard side guard rails 
(K0108) and quick Rls Spox-axel with logo (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that this wheelchair is medically 
necessary for the enrollee. This wheelchair is needed to complete activities of daily living within the home. The 
Plan denied your request. The Plan says the side guards are for use outside of the home and do not serve a 
medical purpose. The quick Rls Spox-axle with logo is for decoration and do not meet a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the aluminum rigid removable standard side guard rails (K0108) and quick Rls Spox-axel with 
logo (K0108).
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 enrollee needs skilled nursing to improve 
medical condition. The Plan denied your request. The Plan says the enrollee's records do not indicate a medical 
condition that needs daily skilled nursing help 
 
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 enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does] not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous fixation device with arthrodesis L3/L4. 
 
You asked the Plan to pre-approve an interspinous fixation device with arthrodesis L3/L4. You say that the 
requested interspinous fixation device with arthrodesis L3/L4 is medically necessary. The Plan denied your 
request. The Plan says the requested interspinous fixation device with arthrodesis L3/L4 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 an interspinous fixation device with 
arthrodesis L3/L4. Our reviewer says that the requested interspinous fixation device with arthrodesis L3/L4 is 
not medically necessary. Our physician reviewer found Interspinous process spacers are experimental. More 
research is needed 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 an interspinous fixation device with arthrodesis L3/L4 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an interspinous fixation device with 
arthrodesis L3/L4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the tooth-shaped cap for bridge (crown) (D6750 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the services is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our physician 
reviewer found the documentation provided does not meet the criteria for coverage for a fixed bridge replacing 
missing tooth #7 with a pontic (D6240) using teeth #'s 6 and 8 as abutment retainers (D6750). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the tooth-shaped cap for bridge (crown) (D6750 x 2).
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. 
The Plan denied your request. The Plan says there is no advantage of moving the enrollee to a long-term acute 
care facility. 
 
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 record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they are not currently 
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not 
satisfied. The requested service cannot be recommended. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested home ventilator is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the home 
ventilator. 
 
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 enrollee does not meet criteria for the home ventilator. Our physician reviewer found the provided 
records in this case document a diagnosis of chronic respiratory failure consequent to chronic obstructive 
pulmonary disease. The 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. Provided records do not document trial and failure of a BiPAP 
device with AVAPS and a back-up rate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: 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 gain all abilities back. The Plan denied your request. The Plan says the enrollee can stay in the 
hospital until they are safe for transfer or discharge. 
 
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 advantage in transferring the enrollee to a LTACH.  The enrollee can 
remain at the current ACH until such time no acute services are required. The enrollee can then be transferred 
or discharged to a lower level of care for any long-term care needs. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited reconsideration 
stating the enrollee meets full acute inpatient rehabilitation criteria. The Plan denied your request. The Plan 
says the enrollee does not meet the criteria for admission to an IRF. 
 
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 enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for December 29, 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 procedure code J2390 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that intra-operative services that are normally a usual and 
necessary part of a surgical procedure are included in the global surgical package.  
 
We looked at the file and Medicare rules. Procedure code J3490 was related to and billed on the same day as 
minor surgical procedure 64483. Payment for code J2390 is included in the global surgical package for code 
64483. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed for December 
29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transperineal placement of hydrogel prostate rectal 
spacer. 
 
You asked the Plan to pre-approve transperineal placement of hydrogel prostate rectal spacer. 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 transperineal placement of hydrogel 
prostate rectal spacer. 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 stage IVB T3c very high-
risk prostate adenocarcinoma. The discussion within the guidelines states that spacer materials are indicated when other techniques [image guided radiotherapy using CT, ultrasound, implanted fiducials, electronic 
magnetic targeting/tacking or endorectal balloons] are insufficient to improve oncologic cure rates and/or 
reduce side effects due to anatomic geometry or other patient related factors, such as medication usage and/or 
comorbid conditions". 
 
Thus, routine use of rectal spacers in patient with Stage 4 disease is not standard of care and not supported by 
published evidence or guidelines. Though not disputed in this case, delivery of 28 fractions of Intensity-
modulated radiation therapy (IMRT) (vs a shorter course of treatment) is also not standard of care in patients 
with Stage 4 disease. 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 transperineal placement of hydrogel prostate rectal spacer have not been met. 
Therefore, we decided that the Plan does not have to pre-approve transperineal placement of hydrogel prostate 
rectal spacer.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot be safely discharged home. The Plan 
denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4261) provided on November 16, 2022. 
 
You asked the Plan to pay for the osseous surgery. You say that if this appeal is approved any payment should 
go to you as you have paid this bill. The Plan denied your request. The Plan says this service is not covered 
under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the osseous surgery is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for osseous surgery 
(D4261) provided on November 16, 2022.