Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the medical services provided at an inpatient level of care from March 
28, 2023, to March 29, 2023. 
 
You asked the Plan to pay for the medical services. You say that this should be covered at the inpatient level of 
care. The Plan denied your request. The Plan says that the records sent in appear to meet the observation level 
of care. The Plan also says that coverage for this level of care was not requested. 
 
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. It appears that the Plans contracted delegate was provided the records for the 
medical services and has failed to forward them to support the decision to deny based on no medical necessity 
for the level of care that was provided. Therefore, we decided that the Plan has to pay for the medical services 
provided at an inpatient level of care from March 28, 2023, to March 29, 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: 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 has had open heart surgery and has a 
history of strokes needing rehabilitation. The Plan denied your request. The Plan says the enrollee's records do 
not show complex rehabilitation needs that require frequent evaluation by a rehabilitation doctor. The Plan says 
that the services needed may be provided safely in a lower level of care.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service coded as 87486, 87502, 87581, 87640, 
U0004, 87632, 87634, 87541, 87496, 87498, 87532, 87798, 87801, 87503 provide January 14, 2022.  
 
You asked the Plan to pay for the laboratory service. You say that this claim was denied in error for not 
medically necessary. Please see the attached chart notes that support the medical necessity of this service. The 
Plan denied your request. The Plan says this service does not meet the medical necessity criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory service have been met. 
The requested documentation to support the medical necessity of the test was not submitted. The records show 
that the Plan made multiple requests to obtain needed medical records from the provider without success. 
Therefore, we decided that the Plan does not have to pay for the laboratory service coded as 87486, 87502, 
87581, 87640, U0004, 87632, 87634, 87541, 87496, 87498, 87532, 87798, 87801, 87503 provide January 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for April 21, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 96365 and 96366 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 96365 is intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure). 
 
We find that CPT code 96365 and 96366 are not supported in the medical record. Specifically, the records 
show that outpatient intravenous insulin treatment (OIVIT) was performed and there are more appropriate 
codes for these services. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
96365 and 96366 billed for April 21, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for  practitioner services provided on March 30, 2023, to April 24, 2023, 
billed with procedure code 86077. 
 
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 that the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the specific denial rationale provided by the Plan is not supported 
since the services were billed for different dates so the MUE denial does not apply. Therefore, we decided that 
the Plan has to pay for  practitioner services provided on March 30, 2023, to April 24, 2023, billed with 
procedure code 86077.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for remote neuromonitoring provided on January 7, 2022. 
 
You asked the Plan to pay for remote neuromonitoring. You say that the services were referred by an in-
network provider at an in-network facility. The Plan denied your request. The Plan says that this claim is a 
duplicate of a previously paid claim and was correctly denied. The Plan says the claim was submitted one day 
after a prior claim (202233935422) for the same date of service, with the only difference being the addition of 
one more Current Procedural Terminology (CPT) code. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. The Plan has not provided a remittance to substantiate 
their denial. Based on this information, we decided that Medicare rules for coverage of remote neuromonitoring 
have been met. Therefore, we decided that the Plan has to pay for remote neuromonitoring provided on 
January 7, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 2, 2022, to 
December 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 
medical records submitted supports diagnosis code A41.9 and code G93.41. The Plan denied your request. The 
Plan says that the submitted documentation was inconsistent or unclear regarding a principal diagnosis code 
A41.9 (sepsis, unspecified organism) and secondary diagnosis code G93.41 (metabolic encephalopathy). 
 
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 code A41.9 (sepsis, unspecified organism) 
and secondary code G93.41 (metabolic encephalopathy). We asked our coder 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 according to coding 
guidelines and documentation in the medical record principal code A41.9 (sepsis, unspecified organism) and 
secondary code G93.41 (metabolic encephalopathy) did not qualify for reporting. Our coder reviewer found 
that the medical records submitted did not include physician or other qualified healthcare provider 
documentation, therefore diagnosis code A41.9 and code G93.41 does not meet criteria.  
 
We looked at this coder 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 December 2, 2022, to December 3, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulation (PNS) device 
(64555, C1778, L8680). 
 
You asked the Plan to pre-approve a SPRINT PNS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 SPRINT PNS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the SPRINT PNS device is experimental for back pain and leg pain. 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 SPRINT PNS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a SPRINT peripheral nerve stimulation (PNS) device (64555, C1778, L8680).
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 would benefit from acute inpatient level 
of care. The Plan denied your request. The Plan says the enrollee does not require intensive rehabilitation 
program and needs could be met in a less restrictive level of care. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records support the medical 
necessity for LTACH admission. The Plan denied your request. The Plan says the enrollee is receiving 
appropriate inpatient care and is currently unstable for transfer to a LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in the current acute care setting. The 
documentation does not support that LTACH services are medically appropriate 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366 and 96521 billed for date of 
service April 12, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366 and 96521. You say that you have billed the 
services at issue correctly. The Plan denied your request. The Plan says the provided 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 96365 is: Intravenous infusion, for therapy, prophylaxis, 
or diagnosis (specify substance or drug); initial, up to 1 hour. The definition of code 96366 is: Intravenous 
infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List 
separately in addition to code for primary procedure). The definition of code 96521 is: Refilling and maintenance of portable pump. 
 
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 codes 96365, 96366 and 96521. Our reviewer says 
that procedure codes 96365, 96366 and 96521 do not meet criteria for payment. Our reviewer found that with 
regard to codes 96365 and 96366, the procedure report describes intravenous insulin treatment provided for an 
outpatient; in this case, there is a more specific HCPCS code that should be reported for the services provided. 
With regard to code 96521, the medical record includes a physician order for refilling and maintenance of 
portable pump; however, performance of the procedure 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 procedure codes 96365, 96366 and 96521 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 96365, 96366 and 96521 billed for date of 
service April 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 58558 billed for January 17, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 58558 is 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 58558 is hysteroscopy, surgical; with sampling (biopsy) 
of endometrium and/or polypectomy, with or without D & C. 
 
We find that CPT code 58558 is not supported in the medical record. Specifically, the operative report does not 
contain documentation of any biopsies, sampling, or curettage. A more appropriate code is available for the 
services performed. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 58558 billed 
for January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G0453, 95910, & 95886 provided on 
November 14, 2022. 
 
You asked the Plan to pay for procedure codes G0453, 95910, & 95886. You say that these servies were 
medically necessary. The Plan denied your request. The Plan says the billed codes 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. 
 
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 codes G0453, 95910, & 95886. Our reviewer says 
that the records do not support the billed codes. Our reviewer found code G0453 is not supported. The 
monitoring physician did not document the amount of time spent monitoring the patient, which is required for a 
time based code. Code 95910 is not supported. The record does not state that 7-8 nerve conduction studies were performed. There is a more appropriate code for the number of conduction studies performed. Code 95886 
requires a primary procedure code as it is an add-on code. No approved primary procedure code was reported, 
therefore this code is not supported. 
 
 
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 codes G0453, 95910, & 95886 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes G0453, 95910, & 95886 provided on November 
14, 2022.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 87801. We decided that the Plan does not have to pay 
for procedure codes 87481 and 87653.  
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87801 billed for date of service November 
30, 2023.. You say that you have billed the services at issue correctly. The Plan says that the provided records 
do not support the services billed. 
 
We decided that the Plan has to pay for procedure code 87801.  
 
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 87801 is: Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) technique. 
 
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 87801. Our reviewer says that procedure 
code 87801 meets criteria for payment. Our reviewer found that the provided medical record includes a urinary 
tract infection (UTI) Panel Coding sheet, documenting tests and assigned codes.  
 
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 87801 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 87801.  
 
We also decided that the Plan does not have to pay for procedure codes 87481 and 87653. 
 
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 codes 87481 and 87653 are column II codes to column I code 87801; 
however, 87481 and 87653 were 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 codes 87481 and 87653. Our reviewer says that 
procedure codes 87481 and 87653 do not meet criteria for payment. Our reviewer found that these procedure 
codes were each reported with appended modifier XU, indicating an unusual, non-overlapping service; 
however, the provided laboratory report does not include documentation to support unusual, non-overlapping 
services. 
 
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 codes 87481 and 87653 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87481 and 87653. 
 
  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.