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

 
We decided that the Plan does not have to pay for procedure code 99285 billed for August 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 99285 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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 these services. Our reviewer says that procedure code 99285 
is not supported. Our reviewer found the enrollee presented to the emergency department (ED) with abdominal pain, myalgia, and burning in the chest and throat with palpitations and head pressure. Aside from a blood 
pressure reading of 177 over 67, her vital signs were stable with an essentially unremarkable examination. 
There was no sign of infection or other acute condition with blood pressure reducing to normal during the ED 
workup. The documentation included an appropriate history and examination; however, it does not support 
medical decision-making of high complexity to justify the code 99285.  
 
We looked at this coder'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 pay for procedure code 99285 billed for August 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95861x2, 95822, and 95999x4 rendered on 
August 24, 2022. 
 
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 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 the denied codes is: 
 
CPT 95822: 
 
Electroencephalogram (EEG); recording in coma or sleep only 
 
CPT 95861: 
 
Needle electromyography; 2 extremities with or without related paraspinal areas 
 
CPT 95999: 
 
Unlisted neurological or neuromuscular diagnostic 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the records do not support that 
two units of CPT 95861 were rendered. Only two limbs had electromyography recordings done. This should be 
reflected as one unit of CPT 95861.  Therefore submission of a claim with an additional unit cannot be said to 
have been supported by the records. 
 
In terms of CPT 95822, the records do not support this code. The enrollee was not "asleep" or in a "coma" 
during the time of this procedure/recording. Rather, they were under anesthesia/sedated and a different CPT 
code should have been submitted to reflect the services under review. 
 
In terms of CPT 95999, train of four testing was done during the procedure to monitor the depth of a 
neuromuscular blockage. However, this service is considered to be part of the reimbursement for the motor 
evoked potentials (MEPs) and EMG performed. Therefore the CPT code under review cannot be said to have 
been rendered as a stand alone procedure. 
 
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 95861x2, 95822, and 95999x4 rendered on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission to be 
provided by an out-of-network (OON) facility. 
 
You asked the Plan to pre-approve a SNF admission. You say that the enrollee has moved in with his daughter 
in a different state and would like a SNF closer to her home. The Plan denied your request. The Plan says the 
enrollee is required to use in-network providers/facilities when available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider/facility in this case is not a network provider/facility with the Plan. The Plan has 
network providers/facilities available who can provide the items/services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan 
does not have to pre-approve a skilled nursing facility (SNF) admission to be provided by an out-of-network 
(OON) facility.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for occupational therapy. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is an in-network provider available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for occupational therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an injection provided on May 17, 2023. 
 
You asked the Plan to reduce the coinsurance for an injection. You say that you were told you would only owe 
$100 for this service, not a 20% coinsurance. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for an injection. This item/service falls within the Medicare Part 
B drugs benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $276.24 ($1,381.20 x 20% = $276.24). Therefore, we decided that the Plan does not 
have to reduce the coinsurance for an injection provided on May 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital inpatient care (99223) provided on June 
12, 2023. 
 
You asked the Plan to pay for the hospital inpatient care. You say that the service was billed correctly and 
should be paid. The Plan denied your request. The Plan says that an evaluation and management note was not 
submitted. This means, the use of the -57 modifier to indicate there was a decision for surgery OR that there 
has been a 90-day global service performed during the preoperative period of a major surgical procedure can't 
be verified. 
 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 hospital inpatient care have been 
met. The appellant did not submit a note showing Evaluation and Management (EM) services provided on the 
billed date of service. Therefore, we decided that the Plan does not have to pay for the initial hospital inpatient 
care (99223) provided on June 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second-opinion consultation on pathology services (88321) 
provided on May 30, 2023. 
 
You asked the Plan to pay for a second-opinion consultation. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that code 88321 describes surgical pathology 
consultation services to review slides, tissues or other material obtained, prepared and interpreted at a different 
location by a different pathologist and referred to another pathologist for a second opinion. This code should 
not be reported by pathologists reporting a second opinion on slides, tissue or other material also examined and 
reported by another pathologist in the same provider group. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a second-opinion consultation have not been met. Specifically, the case record shows that code 
88321, as reported in this case, describes a second opinion on specimens also examined and reported by 
another pathologist in the same provider group. Therefore, we decided that the Plan does not have to pay for a 
second-opinion consultation on pathology services (88321) provided on May 30, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on 
December 23, 2021. 
 
You asked the Plan to waive the copayment the diagnostic mammogram. You say that you were told there was 
no copayment for this service. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Medicare-covered basic radiology services. 
 
You have been asked to pay a $50 copayment for the mammogram. This item/service falls within the outpatient 
diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic 
mammogram provided on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam treatment delivery; intermediate (77523). 
 
You asked the Plan to pre-approve proton beam treatment. You say that you are requesting reconsideration for 
the denied service. The Plan denied your request. The Plan says a review of the literature indicates that proton 
beam radiation therapy is not the standard of care for prostate cancer and Proton Beam therapy for primary 
treatment of prostate cancer should only be performed within the context of a prospective clinical trial. 
 
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 proton beam treatment. 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 clear evidence that proton beam therapy for prostate cancer offers any 
clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a 
possible advantage of this expensive therapy. The generally accepted standard of care for prostate cancer is to 
only offer proton beam therapy on clinical trials, and to not routinely offer it to enrollees. While the National 
Comprehensive Cancer Network (NCCN) guideline consider proton therapy a reasonable alternative they do 
not describe it as being necessary in lieu of non-proton-based treatment and are quite explicit in that there is no 
evidence of its superiority. The decision is unfavorable as the reviewer does not believe Medicare criteria is 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam treatment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam treatment delivery; intermediate (77523).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the traction equipment, cervical, free-standing 
stand/frame, pneumatic, applying traction force to other than mandible (E0849) provided June 8, 2023. 
 
You asked the Plan to pre-approve the traction equipment. You say that please see attached medical records. 
The Plan denied your request. The Plan says the services are not supported in the records - there are no claims 
in the member's history to correspond with the medical records, and the member indicates she did not see the 
doctor and did not order the supplies.  
 
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 traction equipment. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has cervical pain and was referred for traction equipment. The 
physician's documentation does not specifically support that the cervical traction equipment is medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the traction equipment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the traction equipment, cervical, free-standing stand/frame, pneumatic, applying 
traction force to other than mandible (E0849) provided June 8, 2023.
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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care. 
 
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 and/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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test (81479) provided on May 11, 2023. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the requested test does not meet requirement for approval. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter 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 pay for the PrismRA test. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that the current version of the American 
College of Rheumatology (ACR) guideline for the treatment of rheumatoid arthritis does not address the use of 
molecular signature testing. Molecular signature testing offers the potential to improve treatment response by avoiding TNFi therapy when an individual is predicted to be a non-responder. Additional peer-reviewed 
published studies are warranted, including studies with diverse populations, validation of responders versus 
non-responders, and the ability of the test to contribute to the improvement of net health outcomes of 
individuals with rheumatoid arthritis. The ACR provides no guidance regarding molecular signature 
testing. The clinical value and effectiveness of the PrismRA Molecular Signature test in the setting of 
inflammatory arthritis have not been demonstrated in the peer-reviewed literature. The review indicates that the 
enrollee does not meet the LCD 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 PrismRA test have not been met. Therefore, we decided that the Plan does 
not have to pay for the PrismRA test (81479) provided on May 11, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SNF stay provided from July 5, 2023, to July 19, 2023. 
 
You asked the Plan to pay for the skilled nursing facility (SNF) stay. You say that you think the coverage 
should restart for the nursing facility stay because you did not know you were going to have 2 broke hips in a 
six-month period. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $196 
copayment for skilled nursing facility (SNF) care.  
 
  You have been asked to pay a $588 for the skilled nursing facility (SNF) stay ($196 x 3 days = $588).  
 
The records show that you had an SNF stay from March 24, 2023, to March 31, 2023, which is 7 days.  
 
You had an SNF stay from Jun1, 2023, to June 2, 2023, which is 1 day.  
 
Then you had an SNF stay from July 5, 2023, to July 19, 2023, which is 16 days.  
 
You have had a total of 24 days in an SNF (7 days + 1 day + 19 days = 24). This item/service falls within the 
skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the SNF stay 
provided from July 5, 2023, to July 19, 2023.
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 enrollee needs SNF services. The Plan denied 
your request. The Plan says the enrollee does not meet the requirements for a SNF admission. 
 
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 there are no identifiable skilled nursing service needs. There are identifiable skilled 
therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This 
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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: Favorable

 
We decided that the Plan has to pay for procedure code 99223 provided on July 8, 2023. 
 
You asked the Plan to pay for procedure code 99223. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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 Plan has not provided enough evidence to support the denial of 
payment for procedure code 99223 provided on July 8, 2023. The file shows that the enrollee was admitted to 
an outpatient hospital setting on July 5, 2023, and discharged from the outpatient hospital facility July 6, 2023. 
The file also shows that the enrollee presented to the emergency department on July 7, 2023, and from the 
emergency department was admitted to the hospital. These are two separate admissions and procedure code 
99223 is payable as the initial visit for the second admission. Therefore, we decided that the Plan has to pay for 
procedure code 99223 provided on July 8, 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.