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

 
We decided that the Plan does not have to pay for the psychotherapy services coded as 90837 billed for date of 
service June 5, 2023. 
 
You asked the Plan to pay for 90837. You say that 90837 should be covered as billed because requested 
records were provided, and you have completed a request for a prior authorization and sent it to the Plan. The 
Plan denied your request. The Plan says 90837 is denied because it was billed with an inappropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say telehealth services are billed 
with POS 02.  
We looked at the file and Medicare rules. We confirmed that in this case, 90837 was billed with modifier -GT. 
Modifier -GT is used to indicate a service was provided via interactive audio and video telecommunications as 
a telehealth service. In this case, we also confirmed that 90837 was billed with POS 11, indicating an office 
setting, rather than POS 02, as is appropriate for telehealth services. As such, modifier -GT is not supported. 
Based on this information, we decided that Medicare rules for coverage of 90837 have not been met. Therefore, 
we decided that the Plan does not have to pay for the psychotherapy services coded as 90837 billed for date of 
service June 5, 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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee can remain in the current acute care location 
until such time no further acute level care is needed. 
 
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 current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate currently. The 
enrollee's records do not support the need to transfer from one acute hospital to another.  
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 the services (11042) provided on July 6, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the service at issue was 
not billed with the required modifier to allow separate payment within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 28120 
provided on May 5, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the services (11042) provided on 
July 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hematology Profile Plus testing provided on December 
2, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is an 82-year-old woman with a history of follicular lymphoma who had Hematology 
Profile Plus testing performed. This testing is not the standard of care and is not medically reasonable and 
necessary in this case. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Hematology Profile Plus testing provided on December 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 21, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the diagnosis code at 
issue is not appropriate as a primary diagnosis.  
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with primary diagnosis code F05, defined as 
Delirium due to known physiological condition. This code is not an appropriate primary diagnosis as the code 
has a Code first note indicating to code the underlying condition first. Based on this information, we decided 
that Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan does not 
have to pay for the services provided on June 21, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service January 28, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the chart was coded correctly. The Plan denied 
your request. The Plan says an appropriate diagnosis code was not 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. 
 
We looked at the file and the rules. We find that CPT code 99285 was billed with diagnosis code M79.10, 
defined as myalgia, unspecified site. There is a more applicable diagnosis code that describes the enrollees 
condition in this case. 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 procedure code 99285 
billed for date of service January 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy and stab phlebectomy 
(36475, 37766, 37765). 
 
You asked the Plan to pre-approve the vascular services. You say that the enrollee has worn compression 
stockings for over one year. You say that the enrollee reports that this improves their symptoms when walking 
or on their feet a lot. You also say that these services are medically necessary for the enrollee. The Plan denied 
your request. The Plan says treatment of incompetent tributary veins is not covered if saphenous reflux has not 
been eliminated. 
 
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 vascular services. Our reviewer says 
that the requested endovenous ablation therapy and stab phlebectomy are not considered medically reasonable and necessary in this case. Our physician reviewer found Provided records document concern for peripheral 
arterial disease as well as venous disease. The patients exercise ankle brachial index was 0.75 bilaterally. As 
summarized in Up to Date, Approach to treating symptomatic superficial venous insufficiency, Author: Marc A 
Passman, MD: Moderate-to-severe peripheral artery disease  Peripheral artery disease (PAD) is a relative 
contraindication to venous ablation (endovenous, surgical) because of the increased risk for nonhealing 
wounds. Patients with lower extremity ulceration should be assessed to ensure the adequacy of the arterial 
circulation since patients with chronic venous disease complicated with ulceration can have coexistent PAD. 
An appropriate history and ankle-brachial index (ABI) =0.9 identifies patients with PAD. If the arterial 
circulation is inadequate for wound healing (ABI <0.5, absolute ankle pressure <60 mmHg), the arterial disease 
should be addressed prior to treating the venous disease. Patients with mixed arterial/venous ulcers are difficult 
to manage, and the patient should be referred to a vascular specialist. While less common, if there is decreased 
perfusion due to nonatheromatous vascular diseases (eg, popliteal entrapment, adventitial cystic disease), these 
arterial disorders should be addressed first prior to any venous interventions. Therefore, the reviewer found that 
the requested endovenous ablation therapy and stab phlebectomy are 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 the vascular services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve endovenous ablation therapy and stab phlebectomy (36475, 37766, 37765).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found it's not clear that this study is being done 
as part of a research study that meets all the requirements for performance of a Beta Amyloid scan. The 
enrollee has previously had a PET/CT of their brain and the NCD indicates that there is a limit of 1 brain PET 
scan. With this, the requested service does not meet criteria for coverage. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
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 is unable to do rehabilitation at home as 
there is no one to take care for the enrollee. The Plan denied your request. The Plan says the enrollee's records 
do not show complex rehabilitation needs which require a rehabilitation physician. The Plan says services may 
be provided at 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.  The medical 
records supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. It is not a 
reasonable expectation that the 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 the neuromuscular services coded as 95937 performed on 
June 29, 2023. 
 
You asked the Plan to pay for 95937. You say that 95937 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 95937 is denied because it is not supported in the 
documentation. 
 
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 95937. Our reviewer says that 95937 is not supported in the 
provided documentation. Our reviewer found the record states that 95937 was used to report train of four 
testing for intraoperative neuromonitoring. According to CPT and National Correct Coding Initiative (NCCI) 
rules, train of four testing is included in the intraoperative neuromonitoring and cannot be reported separately. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95937 have not been met. Therefore, we decided that the Plan does not have to 
pay for the neuromuscular services coded as 95937 performed on June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 28, 2023. 
 
You asked the Plan to pay for laboratory services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the requested services are experimental or 
investigational are excluded from coverage under the enrollee's Plan. 
 
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 laboratory services. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found urine polymerase chain reaction (PCR) amplification techniques raise considerable concerns 
regarding contamination from one specimen to another, creating the potential for false-positive results. The 
clinical interpretation of PCR results may also be challenging. Amplification of organisms representing latent infection or colonization cannot be distinguished from active, clinically significant infections. Additionally, 
PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus further clouding the 
clinical interpretation. Finally, specificities, sensitivities, and positive and negative predictive values of PCR 
have not been reported in large groups of patients for many of the microorganisms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services provided on March 28, 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 these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the required services can be provided in an alternate 
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 nursing, medical and rehabilitation can be provided 
in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary approach 
to rehabilitation care. The enrollee requires treatment by multiple therapies, including physical therapy and 
occupational therapy, but this can be provided in a lower level of care. There is documentation that there is a 
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF, but the services required can be provided at 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 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to go to inpatient rehabilitation to 
become more independent and to be able to return home and be safe on your own. The Plan denied your 
request. The Plan says based on Medicare guidelines, the Inpatient Rehabilitation Facility (IRF) services 
requested do not meet the requirements for approval.  
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
supports a need for physical and/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 pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the request is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines, the inpatient rehabilitation facility (IRF) services 
requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/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.