Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are medically 
necessary. The Plan denied your request. The Plan says there is no documentation provided to support the 
expectation the enrollee will require a greater than 2 midnight stay. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the record indicates that the enrollee is scheduled for L5-S1 synovial cysts 
resection and decompression. The record provided does not indicate that the treating physician has a reasonable 
expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors. The 
initial day may be spent in observation until it is clearly expected that a second midnight would be required, at 
which time the physician may order inpatient admission. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation (20985). 
 
You asked the Plan to pre-approve computer-assisted surgical navigation. You say that you want the Plan to 
cover this service. The Plan denied your request. The Plan says there are not enough studies on computer 
assisted surgical navigation to show it is safe and effective. 
 
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 computer-assisted surgical navigation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is insufficient literature to support the safety and efficacy, as 
defined by Medicare rules, of the requested service. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted surgical navigation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computer-assisted surgical navigation (20985).
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 are appealing the denial for IRF. The Plan 
denied your request. The Plan says that medical necessity has not been met and that the enrollee meets skilled 
nursing guidelines. 
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6456, A6454, and A6196 provided on 
August 18, 2022. 
 
You asked the Plan to pay for procedure codes A6456, A6454, and A6196. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered as billed. 
 
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise 
code that most fully explains the narrative description of the symptom or diagnosis. 
 
We looked at the file and Medicare rules. The file shows that procedure codes A6456, A6454, and A6196 were 
billed with one or more diagnosis codes that were inappropriately coded. Medicare rules say that some ICD-10-
CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not 
appropriate to report left and right when a more specific bilateral diagnosis code is available. Therefore, we 
decided that the Plan does not have to pay for procedure codes A6456, A6454, and A6196 provided on August 
18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspiration. 
 
You asked the Plan to pre-approve a bone marrow aspiration. You say that you are requesting reconsideration 
of the denied authorization. The Plan denied your request. The Plan says that the requested procedure 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 a bone marrow aspiration. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that a bone marrow aspiration is experimental, and more research is needed. 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 bone marrow aspiration have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a bone marrow aspiration.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218), and 
knee pad (A9270). 
 
You asked the Plan to pre-approve a fluid circulating cold pad with pump and knee pad. You say that you 
believe this machine will help you. You also say that you are on a fixed allowance and cannot afford this. The 
Plan denied your request. The Plan says these items or services do not meet the coverage criteria. The Plan also 
says that since A9270 is a component to be used with E0218, with E0218 being denied, then A9270 is also 
subsequently denied. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump and knee pad have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218), and knee pad (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 95937 billed for date of service March 29, 2022. 
 
You asked the Plan to pay for code 95937. You say that code 95937 is not supported by the medical record. 
The record indicates that the service provided was Train-of-Four testing, which does not meet the definition of 
95937. Train-of-Four testing is bundled into other services and is not separately payable. The Plan denied your 
request. The Plan says the medical records support payment of 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. 
 
In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing [repetitive 
stimulation, paired stimuli] each nerve, any one method. 
 
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 code 95937. Our reviewer says that code 95937 is not 
supported in the medical records. Our reviewer found the record states that train of four was performed as part 
of intraoperative neuromonitoring. This is not separately reportable with CPT code 95937. No neuromuscular 
junction testing was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 95937 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 95937 billed for date of service March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is 
correct. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet criteria for inpatient psychiatric level of care. Our physician reviewer 
found it is not expected that the enrollee would improve in a reasonable period of time beyond the date in 
question as the enrollee is not showing any dangerousness to self or others, auditory or visual hallucinations, 
aggressive behaviors, or acute threats to safety. It does not appear medically reasonable and necessary to have 
psychiatric care provided at the inpatient level of care rather than a lower 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9351 billed for date of service January 1, 
2023. 
 
You asked the Plan to pay for procedure code S9351. You say that your contract says that this code is correct. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9351 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9351 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9351 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9351 billed for date of service January 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service September 20, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided 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 the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for date of 
service September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81479 for date of service February 24, 2023. 
 
You asked the Plan to pay for procedure code 81479. You say that you disagree with the Plan's 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 procedure code 81479 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 81479 for date 
of service February 24, 2023.
Appeal type: Surgery
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 Intracept procedure is medically 
necessary. The Plan denied your request. The Plan says the Intracept procedure 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 Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found that there is no magnetic resonance imaging showing only Modic changes 
without facet joint syndrome or foraminal stenosis. The cause of back pain is not clear. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 for date of service June 17, 2022, to 
June 24, 2022. 
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, the documentation does not 
include a subsequent hospital care evaluation and management service for the billed date of service. Based on 
this information, we decided that Medicare rules for coverage of procedure code 99232 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 99232 for date of service June 17, 
2022, to June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular complete denture (D5120) provided on 
October 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 26, 2022. 
Therefore, we decided that the Plan does not have to pay for the mandibular complete denture (D5120) 
provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electroencephalogram (EEG) during non-intracranial surgery 
(95955) nerve conduction studies (95908) and short-latency somatosensory evoked potential (SSEP) study 
(95927) provided March 3, 2021. 
 
You asked the Plan to pay for the intraoperative neuromonitoring services . You say that these services are a 
medically necessary service requested by an in-network surgeon. The Plan denied your request. The Plan says 
the service is not supported in the medical records submitted. 
 
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 95955 is electroencephalogram (EEG) during non-
intracranial surgery; CPT code 95908 is nerve condition studies, for 3-4 studies and CPT code 95927 is short-
latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording 
from the central nervous system, in the trunk or head. 
 
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 intraoperative neuromonitoring services . Our reviewer 
says that the records do not support the billed services. Our reviewer found CPT code 95955 is not supported. 
The documentation states that an EEG was performed for intraoperative monitoring purposes. There is no 
interpretation or report showing that a diagnostic EEG was performed. This is considered part of the 
intraoperative neuromonitoring services and is not reported separately. Code 95927 is not supported. The 
record does not contain evidence that SSEP testing was performed with recordings in the trunk or head. The 
peripheral SSEP that was documented is included in another code that has already been approved. Code 95908 
is not supported. The record does not contain evidence that 3-4 diagnostic nerve conduction studies were 
performed. The nerve conduction documented was part of intraoperative neuromonitoring and not separately 
reportable.  
 
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 intraoperative neuromonitoring services have not been met. Therefore, we 
decided that the Plan does not have to pay for electroencephalogram (EEG) during non-intracranial surgery 
(95955) nerve conduction studies (95908) and short-latency somatosensory evoked potential (SSEP) study 
(95927) provided March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you do not have a contract 
with the Plan, and the labs are reimbursable. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 21, 2022.