Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on July 26, 2023. 
 
You asked the Plan to pay for the home health services. You say that this claim should be reprocessed for 
payment. The Plan denied your request. The Plan says this claim was billed with an incorrect Type of Bill 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that he Type of Bill code is a 4-digit alphanumeric 
code that gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit 
indicates the sequence of this bill in this particular period of care. The acceptable 4th digit options are as 
follows: 7 (to indicate a replacement of a prior claim); 8 (to indicate a void or cancel of a prior claim); and 9 (a 
final claim). 
 
 Based on this information, the correct Type of Bill for the services at issue is 329.  Instead, you billed with 
Type of Bill 323, which is not correct. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to 
pay for home health services provided on July 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 23, 2022, to 
October 22, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe the NOA was filed on 
November 23, 2022. The Plan denied your request. The Plan says the NOA was not received timely. As such, 
this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 23, 2022. The NOA was not received by the Plan until January 
11, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 23, 2022, to October 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complex cataract surgery (66982). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan follows Medicare rules. Medicare rules say that complex cataract surgery will be considered 
medically reasonable and necessary when one of the indicated criteria has been met.   
 
 
 
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 this service. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested service. Our physician reviewer found that in this 
case, there is no documentation of a miotic pupil requiring a mechanical iris expansion device (iris hooks, 
Malyugin ring). There is history of a vitrectomy and it has been indicated that there is a possible need for a 
capsular tension ring. However, there is no exam findings of zonular weakness or an operative report indicating 
the use of a capsular tension ring. Therefore, Medicare criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve complex cataract surgery (66982).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on June 15, 2023. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for Medicare Part B prescription drugs provided on June 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs this care to return to prior level of 
independence. The Plan denied your request. The Plan says the enrollees medical condition does not require 
IRF services, and care can be provided in another setting.  
 
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 medical, rehabilitation, and nursing needs does not 
require IRF care with an interdisciplinary approach to rehabilitative care. While the medical records support 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation services 
provided on March 25, 2023, to March 29, 2023. 
 
You asked the Plan to waive the copayment for the acute inpatient rehabilitation services. You say that you say 
that you disagree with the copayment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for inpatient hospital care. 
 
You have been asked to pay a $250 copayment for the acute inpatient rehabilitation services. This item/service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. The enrollee has been asked to pay a $250 copayment, which is less than the 
$250 copayment per day for the four days the enrollee received inpatient hospital care. Therefore, we decided 
that the Plan does not have to waive the copayment for the acute inpatient rehabilitation services provided on 
March 25, 2023, to March 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 23, 2022, billed 
with procedure codes 95861-26, 95861-26-XU, 95822-26, and 95999 (x3). 
 
You asked the Plan to pay for the practitioner services provided. 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 codes, 
the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that submitted claims in 
which the unit of service exceeds the MUE value cannot be paid when the MAI value is 3, unless there is 
evidence justifying the excess units.  
 
In this case, the CPT Code Manual definition of codes 95861-26, 95861-26-XU, 95822-26, and 95999 (x3) is 
electroencephalogram (EEG); recording in coma or sleep only, unlisted neurological or neuromuscular 
diagnostic procedure, and needle electromyography; 2 extremities with or without related paraspinal areas. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the provider reported procedure code 
for baseline electroencephalogram (EEG) testing for L4-L5 decompression procedure, however there is a more 
specific code that should be reported for service provided. The provider reported an unlisted procedure code for 
train of four during interoperative neuromonitoring service. However, it is not appropriate to bill separately for 
train-of-four (TOF) monitoring. The American Medical Association (AMA) has clearly stated that CPT code 
95937 is not appropriate for this procedure, nor may TOF monitoring be billed with an unlisted code. 
 
In this case, the MUE for CPT code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on August 23, 2022, billed with procedure 
codes 95861-26, 95861-26-XU, 95822-26, and 95999 (x3).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for right and left coronary artery lithotripsy provided on June 9, 
2023. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental and investigational. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical appropriateness and necessity of coronary artery lithotripsy (CAL) in 
managing calcified stenosis in a coronary artery. While clinical studies led to Food and Drug Administration 
(FDA) approval several years ago, CAL remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically 
rigorous studies are completed, it is premature to presume clinical outcomes and benefit. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for right and left coronary artery lithotripsy provided on June 9, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollee's nursing, medical, and rehabilitation needs does require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has been decannulated and 
his percutaneous endoscopic gastronomy (PEG) tube has been removed. The enrollee does require the 
oversight of a rehabilitation physician given his multiple medical conditions and traumatic brain injury. The 
enrollee does require rehabilitation nursing, including complex wound care. His medical and rehabilitation 
needs do require the intensive interdisciplinary approach provided on acute inpatient rehabilitation. The 
enrollee does require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. Currently, he requires maximum assistance for toileting and 
bathing and moderate assistance for dressing. He is dependent for transfers and mobility. He is tolerating 
therapy and following commands consistently. The enrollee has had a decline from his baseline level of 
function and would benefit from the intensity of therapies provided in an acute inpatient 
rehabilitation. Therefore, the acute inpatient rehabilitation admission is medically 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675, E0673) provided 
on May 1, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (E0675, E0673) provided on May 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteogenesis stimulator, electrical, noninvasive, other 
than spinal applications (E0747). 
 
 You asked the Plan to pre-approve an osteogenesis stimulator. You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says the request is not medically necessary because your records do not 
show radiographic evidence that fracture healing has ceased for three or more months prior to starting 
treatment with the osteogenesis stimulator. 
 
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 osteogenesis stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not reveal nonunion of a long bone fracture documented by a 
minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, 
separated by a minimum of 90 days, each including multiple views of the fracture site, and with a written 
interpretation by a treating practitioner stating that there has been no clinically significant evidence of fracture 
healing between the two sets of radiographs. L33796 criteria have not been met for this device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of osteogenesis stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an osteogenesis stimulator, electrical, noninvasive, other than spinal applications 
(E0747).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan with concurrently 
acquired computed tomography (CT) scan (78816). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that the enrollee is not able to have a computed 
tomography angiography (CTA) or magnetic resonance imaging (MRI) due to renal dysfunction. You say the 
PET/CT scan is needed to assess larger vessels given giant cell arteritis. The Plan denied your request. The 
Plan says that the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 PET/CT scan. Our reviewer says that 
the service is medically necessary. Our physician reviewer found a PET/CT scan is a useful tool in the workup 
of inflammatory diseases absent malignancy, and this is such a case. The great vessels, aorta and large 
branches, will often show increased metabolic activity with PET imaging which would then offer a tool to 
measure progress in the treatment of giant cell arteritis. A PET/CT scan is a useful tool in patients with 
inflammatory disease in whom MRI or CT scan with contrast is contraindicated. The exam should be approved. 
 
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 PET/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan with concurrently acquired computed tomography (CT) 
scan (78816).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36556 rendered on May 11, 2023. 
 
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 Current Procedural Terminology (CPT) 36556 remains 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 36556 is "Insertion of non-tunneled centrally inserted 
central venous catheter; age 5 years or older." 
 
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 the documentation does not 
support that a non-tunneled central venous catheter (also known as a non-tunneled central line) was performed. There is no mention of any central venous catheter placement in the operative note provided. There 
is no mention if the catheter withdrew blood or could be flushed. Pacing wires are not central venous catheters 
and would be subject to alternative cardiac procedural coding rules. 
 
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 procedure code 36556 rendered on May 11, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 5, 2023, to July 7, 
2023. 
 You asked the Plan to pay for the home health services. You say that payment is due even if the NOA was late. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is June 5, 2023. The NOA was not received by the Plan until July 24, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
July 5, 2023, to July 7, 2023.