Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neurophysiologic monitoring coded as 
95957, 95861, 95865 and G0453 provided April 5, 2023. 
 
You asked the Plan to pay for the intraoperative neurophysiologic monitoring. You say that the intraoperative 
neurophysiologic monitoring services are medically necessary as per the ordering physician. The Plan denied 
your request. The Plan says the records do not support the service 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 95957 is digital analysis of electroencephalogram (EEG), 
code 95861 is needle electromyography; 2 extremities with or without related paraspinal areas, code 95865 is 
needle electromyography; larynx and code G0453 is continuous intraoperative neurophysiology monitoring, 
from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) 
each 15 minutes (list in addition to primary procedure). 
 
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 neurophysiologic monitoring. Our 
reviewer says that the procedure codes are not supported in the medical records. Our reviewer found the 
procedure report does not include documentation of digital analysis of electroencephalogram.  For CPT 95957, 
in this procedure, the provider performs computer-based analysis of an electroencephalogram. This procedure 
was not found in medical record and therefore cannot be verified. For CPT 95861, the procedure report does 
not include documentation to support needle electromyography; 2 extremities.  The procedure report describes 
a limited study, and in this case, there is a more specific code to report for service provided. For CPT 95865, 
the procedure report does not include documentation of larynx needle electromyography. The provider uses an 
electromyograph to record electrical activity that muscle cells produce while the provider inserts needles into 
the muscles of the larynx. The provider can hear the recordings on a loudspeaker.  This procedure was not 
found in medical record and therefore cannot be verified. For G0453, the provider reported procedure code 
with appended modifier XU unusual non-overlapping service to bypass NCCI Edit with CPT 95957, however 
in this case, CPT 95957 is not supported, therefore this 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 the intraoperative neurophysiologic monitoring have not been met. Therefore, 
we decided that the Plan does not have to pay for the intraoperative neurophysiologic monitoring coded as 
95957, 95861, 95865 and G0453 provided April 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 3, 
2023. 
 You asked the Plan to pay for procedure code 81456. The Plan denied your request. The Plan says payment for 
code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 81456 billed for date of service January 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) liquid biopsy (0037U) 
provided May 3, 2023. 
 
You asked the Plan to pay for the genetic testing. You say that the provision of F1CDx meets the requirement 
of the NCD and has been determined by CMS to be reasonable and necessary for the management of the 
enrollee's advanced cancer. The Plan denied your request. The Plan says based on Medicare guidelines, the 
genetic test FoundationOne Liquid Biopsy requested does not meet the requirements for approval. 
 
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. The records do not show that the enrollee's cancer is one that has 
returned (recurrent or relapsed), cancer that does not respond to treatment (refractory), cancer that has spread 
(metastatic), or advanced (stage III or IV) cancer. In addition, medical literature recommends a tissue-based test 
over a liquid biopsy test. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne 
CDx (F1CDx) liquid biopsy (0037U) provided May 3, 2023.
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 you are requesting reconsideration for 
the denial of an LTACH admission based on medical necessity. The Plan denied your request. The Plan says 
the requested service is not medically necessary. 
 
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 appears to be responding to current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
stable and appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires 
that are not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve micrographically oriented histographic surgery (Mohs) 
surgery (17313, 17314). 
 
You asked the Plan to pre-approve Mohs surgery. You say that the enrollee has a right distal dorsal forearm 
invasive moderately differentiated squamous cell carcinoma located on right forearm in an area of high 
recurrence with a MAUC score of 7. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Mohs Micrographic Surgery may be indicated for 
squamous cell carcinomas (SCC) in trunk and extremities regardless of subtype, size, or depth arising in: prior 
radiated skin, traumatic scar, area of osteomyelitis, rea of chronic inflammation/ulceration, or patients with 
genetic syndromes. 
 
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 Mohs surgery. Our reviewer says that 
the requested Mohs surgery is not medically necessary. Our physician reviewer found the provided 
documentation does not indicate why the lesion could not be addressed by excision. The reviewer also found 
that the documentation does not indicate squamous cell carcinomas (SCC) in trunk and extremities regardless 
of subtype, size, or depth arising in prior radiated skin, traumatic scar, area of osteomyelitis, area of chronic 
inflammation/ulceration, or patients with genetic syndromes. As a result, the reviewer found that the requested 
Mohs surgery is not medically reasonable or 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 Mohs surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve micrographically oriented histographic surgery (Mohs) surgery (17313, 17314).
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 inpatient rehabilitation facility 
services to regain strength and perform daily activities. The Plan denied your request. The Plan says inpatient 
rehabilitation facility services are not medically necessary.  
 
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 enrollee's medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve grafting of autologous fat as a treatment for 
osteoarthritis. 
 
You asked the Plan to pre-approve grafting of autologous fat as a treatment for osteoarthritis. You say that you 
would like to avoid costly, invasive surgery by opting for autologous fat grafting. The Plan denied your 
request. The Plan says that the literature is lacking sufficient studies supporting long-term efficacy, and 
therefore, the proposed treatment remains investigational and non-covered. 
 
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 grafting of autologous fat as a treatment 
for osteoarthritis. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that limited published, large-scale, long-term peer-
reviewed literature shows this request to be an effective and/or safe treatment for the noted pathology. No 
compelling rationale is presented, or extenuating circumstances noted, to support the medical necessity of this 
request as an exception to guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of grafting of autologous fat as a treatment for osteoarthritis have not been met. 
Therefore, we decided that the Plan does not have to pre-approve grafting of autologous fat as a treatment for 
osteoarthritis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) testing (84443) 
provided on May 18, 2023.  
You asked the Plan to pay for the TSH testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing is not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the TSH testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
thyroid stimulating hormone (TSH) testing (84443) provided on May 18, 2023.
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 enrollee meets LTACH admission 
criteria. The Plan denied your request. The Plan says that the enrollee does not meet all of the requirements for 
LTACH admission. 
 
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 that the enrollee continues to require excessively high FiO2 (fraction of inspired 
oxygen) on high-flow nasal cannula and requires intravenous diuretics and therefore has not completed the full 
course of treatment in the acute care setting. There is no documentation provided indicating medical necessity 
for admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH 
that the enrollee requires that are not available at the health care setting being offered by the Plan. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 8, 2023, billed with 
procedure code 0241U. 
 
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 code. 
 
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 0241U is Infectious disease (viral respiratory tract 
infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], 
influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen 
reported as detected or not detected. 
 
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 code. Our reviewer found that there is a more specific code to report 
for service provided. 
 
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 May 8, 2023, billed with procedure code 
0241U.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 5, 2022, to 
December 15, 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 
secondary diagnosis G95.19 is supported in the documentation, therefore the claim should be paid at the DRG 
originally billed. The Plan denied your request. The Plan says G95.19 is not supported in the documenation. 
 
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 secondary diagnosis G95.19, defined as other 
vascular myelopathies. 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 diagnosis code G95.19 is not supported in the 
documentation. Our physician reviewer found documentation shows the enrollee underwent C3-6 posterior 
laminoplasty and C6-7 foraminotomy due to cervical stenosis. The documentation does not support a vascular 
etiology to the enrollees spinal stenosis, so code G95.19 is not supported.  
 
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 December 5, 2022, to December 15, 2022, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99205 billed for date of service April 5, 2023. 
 
You asked the Plan to pay for the billed services. You say that the level of service was reported accurately. The 
Plan denied your request. The Plan says that the billed code 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 99205 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and high 
level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on 
the date of the encounter. 
 
We asked our physician 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 billed services. Our reviewer found that the enrollee 
has a history of breast cancer who presented for adjuvant radiation therapy consideration following mastectomy 
and adjuvant chemotherapy. The documentation does support a high level of medical decision making. 
 
We looked at this physicians review, the file, and Medicare rules. This is an either/or situation, where either 
the history/exam and complexity of the decision making must be documented, or the time spent can be used to 
select the code. Based on this information, we decided that Medicare rules for coverage of the billed services 
have been met. Therefore, we decided that the Plan has to pay for procedure code 99205 billed for date of 
service April 5, 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: 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 you need extended SNF care. The Plan denied your 
request. The Plan says medical records show you do not have inability to complete activities of daily living. 
 
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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily 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 skilled nursing facility (SNF) care.