Persius/hicric huggingface dataset:
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 the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a skilled nursing 
facility (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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) with an in-network tertiary 
hematologist/oncologist. 
 
You asked the Plan to pre-approve an office visit. You say that you had cancer twelve years ago of the neck 
and throat. You have now been diagnosed with prostate cancer and are having issues again with your neck and 
throat and you would like to see an oncologist at the requested facility. The Plan denied your request. The Plan 
says you do not meet the guidelines for tertiary care. 
 
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 an office visit. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the prostate adenocarcinoma (adenoCA) may be addressed by in-network physicians as it is a 
common cancer seen and treated, and there are no documented features in the diagnosis that would warrant 
tertiary center 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 an office visit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an office visit (99204) with an in-network tertiary hematologist/oncologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasonic guidance, intraoperative (93799-59-26) 
provided on August 7, 2022. 
 
You asked the Plan to pay for the ultrasonic guidance. You say that the claim should be paid. The Plan denied 
your request. The Plan says the payment modifier is required to be in the first position when billed unless 
another payment modifier is submitted in the first position. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Procedure code 93799 was billed with the Modifier 59 in the first position and the Modifier 26 in the second 
position. Payment modifiers include: 22, 26, 50, 51, 52, 53, 54, 55, 58, 62, 66, 78, 79, 80, 81, 82, AA, AD, AS, 
TC, QK, QW, and QY. Informational or statistical modifiers (e.g., any modifier not classified as a payment 
modifier) should be listed after the payment modifier. Since the Payment Modifier is 26 and is listed in second position, the procedure 93799 is unpayable. If appropriate, the provider may submit a corrected claim for 
payment consideration. Based on this information, we decided that Medicare rules for coverage of the 
ultrasonic guidance have not been met. Therefore, we decided that the Plan does not have to pay for the 
ultrasonic guidance, intraoperative (93799-59-26) provided on August 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units of procedure code 64488 rendered on April 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 the documentation does not support the extra units 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 64488 is "Transversus abdominis plane (TAP) block 
(abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when 
performed)." 
 
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 a TAP block was not found as 
performed in the procedure report. The code and the units billed is not able to 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for two units of procedure code 64488 rendered on April 11, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular junction testing (95937) provided on 
February 23, 2023. 
 
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. 
The Plan says the medical records submitted indicate that train of four testing was performed. The Plan states 
Current Procedural Terminology (CPT) code 95937, neuromuscular junction testing (repetitive stimulation, 
paired stimuli), each nerve, any one method was billed. The Plan states train of four testing does not fit the 
criteria for this code as it is inappropriate to bill the code for neuromuscular junction when train of four 
monitoring is performed. The Plan states there is no separate CPT code for train of four monitoring.  
 
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 1 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 the testing. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. The provider reported neuromuscular junction test procedure code, for 
Train of Four (T04) performed. A code does not exist for T04, as this procedure is inclusive to the primary 
neuromonitoring procedure code and not separately reported. CPT 95937 (neuromuscular junction testing 
(repetitive stimulation, paired stimuli) each nerve, any one method) is used for Neuromuscular Junction Testing 
and should not be used for Train of Four (TOF) Monitoring. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the neuromuscular junction testing (95937) provided on February 23, 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 has strong criteria for 
admission including aggressive ventilator weaning with a multitude of medical comorbidities and stable for 
transfer The Plan denied your request. The Plan says the enrollee does not meet all the requirements; care can 
be provided in the current inpatient hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health 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: 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 requires inpatient acute rehabilitation in 
effort to facilitate increased independence and return home and to the community with improved quality of life. 
The Plan denied your request. The Plan says the enrollee does not meet the requirements. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically complex and 
LTACH services would provide the most appropriate and needed level of care. The Plan denied your request. 
The Plan says that the enrollee does not meet the requirements for admission to an 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 that the documentation does not support that LTACH services are medically 
appropriate. The enrollee is receiving the appropriate care in the current acute care setting as provided by the 
Health 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 LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services (76937) provided on April 5, 2023. 
 
You asked the Plan to pay for the ultrasound. You say that code 61645 does not include ultrasound guidance 
for vascular access. You state that it is appropriate to report code 76937 in conjunction with this code, 
assuming all of the requirements for the guidance service are met.  The Plan denied your request. The Plan says 
76937 was not billed with an appropriate primary procedure 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 76937 is ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
separately in addition to code for 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 ultrasound. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. The procedure 76937 is an add-on code, which would be 
reported with an appropriate procedure code. The descriptor for CPT code 76937 includes all phases of actual 
guidance, documentation, and reporting required to perform this procedure. Use of CPT code 76937 requires a 
permanent recorded image(s) of the vascular access site to be included in the enrollee record as well as a 
documented description of the process either separately or within the procedure report. Therefore, it is not 
appropriate to report CPT code 76937 for ultrasound guidance when ultrasound is utilized only to identify a 
vein, mark a skin entry point, and proceed with non-guided puncture, (Note: CPT code 76942 should not be 
reported with CPT code 76937.) 
 
Effective immediately, the base CPT codes for this ultrasound guidance procedure will be payable only for 
certain venous access procedures. These are: 
 
CPT code 36000 
CPT code 36005 
CPT code 36010 
CPT code 36011 
CPT code 36012 
CPT code 36481 
CPT code 36500 
CPT codes 36555 - 36585 
CPT code 36581 
This review was referenced, American Academy of Professional Coders (AAPC) for CPT code billed.  The 
primary procedure billed in addition to the add-on procedure code cannot 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 ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for the ultrasound services (76937) provided on April 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has interstitial lung disease 
associated with Sjogren syndrome and obstructive sleep apnea (OSA). The Life2000 system is not a true 
ventilator because it is not capable of providing full ventilatory support. The criteria for coverage are not met 
and the services are not medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76881, 76942, 99214, and J2001 rendered 
on March 21, 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 the denied codes remain 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 the denied codes is: 
 
CPT 76881: 
 
Ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation 
 
CPT 76942: 
 
Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 
supervision and interpretation 
 
CPT 99214: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and moderate level of medical decision making. When using 
time for code selection, 30-39 minutes of total time is spent on the date of the encounter 
 
Healthcare Common Procedure Coding System (HCPCS) J2001: 
 
Injection, lidocaine hcl for intravenous infusion, 10 mg 
 
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 recodrs. Our reviewer found that the medical records do not 
contain documentation of a complete joint ultrasound; therefore, CPT 76881 is not supported. The procedure 
report does include ultrasound guidance for needle placement; however, the diagnostic portion of this 
procedure cannot be verified, and CPT 76942 is not supported. In terms of CPT 99214, the records do not 
support this procedure or the appended modifier 25. The evaluation and management service provided was for 
the injection. Additionally, the records do not support an appropriate history or exam, and the medical decision 
making level was low. Finally, in terms of J2001, the procedure report describes a right shoulder injection. 
J2001 is used for reporting intravenous infusion. There is a more appropriate code to use for right shoulder 
injection. 
 
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 codes 76881, 76942, 99214, and J2001 rendered on March 21, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64629, 64628). 
 
You asked the Plan to pre-approve an Intracept procedure. 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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet degenerative joint disease (DJD) or foraminal stenosis. The cause of the pain is not clear.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64629, 64628).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. The Plan denied your request. The Plan says 
the radiofrequency ablation is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found the 
radiofrequency ablation is the subject of ongoing clinical trials and is considered experimental and 
investigational. 
 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain requirements are 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 an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found documentation does 
not show recent physical therapy, chiropractic or other conservative therapy. Only one intervention per session 
is standard of care. Transforminal and Interlaminar ESI on the same day does not meet the coverage criteria. 
The request, therefore, is deemed not medically reasonable and 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 an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.