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

 
We decided that the Plan does not have to pay for assistant surgeon services provided for procedure code 
61781 for date of service April 5, 2023. 
 
You asked the Plan to pay for the assistant surgeon services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services provided were not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for Current Procedural 
Terminology (CPT) code 61781. The Medicare Fee Schedule Database contains a surgical indicator of 0 for 
this procedure.  
 
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 assistant surgeon services. Our reviewer 
says that the documentation does not support that the assistant surgeon services were medically reasonable or 
necessary. Our physician reviewer found review of the operative report does list the Advanced practice 
registered nurse (APRN) as the Assistant, but the surgeon did not specify in the body of the operative report 
what the assistant actually did. The medical records do not include supporting documentation to establish 
medical necessity of the assistant surgeon services provided. Therefore, the enrollee did not meet criteria for 
the services rendered. 
 
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 assistant surgeon services have not been met. Therefore, we decided that the 
Plan does not have to pay for assistant surgeon services provided for procedure code 61781 for date of service 
April 5, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve difluprednate ophthalmic emulsion. 
 
You asked the Plan to pre-approve the medication. You say that your provider says this is the only medication 
that will help solve a problem with your eyesight. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve difluprednate ophthalmic 
emulsion.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says a facet joint 
injection 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 injection. Our reviewer says that the 
enrollee does not meet the LCD coverage criteria. Our physician reviewer found that the enrollee has not 
completed two medically reasonable and necessary diagnostic facet joint procedures with each one providing a 
consistent minimum of 80% pain relief. The requested L3, L4, and L5 medial branch blocks do not meet the 
coverage criteria and are not medically necessary or reasonable. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a facet joint injection.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF services requested are medically necessary.  
The Plan denied your request. The Plan says that the skilled nursing facility (SNF) services requested do not 
meet the requirements for approval. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the enrollee qualifies for SNF coverage.  The 
enrollee has documented skilled therapy needs.  Daily skilled services are required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance transport services (codes A0428, A0425, and 
A0382) to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the ambulance transport services. You say that the enrollee is bedridden and 
has no transportation to dialysis and doctors appointments. The Plan denied your request. The Plan says there 
are two transportation providers who participate with the enrollee's health plan and are available and able to 
provide comparable services to the enrollee. The Plan also says no medical need is shown as to why the 
enrollee cannot get this non-emergent ambulance transport if medical need is met from an in-network 
ambulance provider. 
 
 
 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 
ambulance transport services (codes A0428, A0425, and A0382) to be provided by an out-of-network (OON) 
provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 71271, defined as computed tomography, thorax, low 
dose for lung cancer screening, without contrast material(s) performed on February 13, 2023. 
 
You asked the Plan to pay for code 71271. You say that 71271 should be paid as billed because the diagnosis 
assigned is correct. The Plan denied your request. The Plan says 71271 is denied because it was billed with a 
diagnosis code that does not indicate that the enrollee is currently a smoker or a former smoker who has quit in 
the last 15 years. 
 
The Plan must follow Medicare rules. Medicare rules say that for coverage of lung cancer screening with 
LDCT, enrollees must be between ages 50-77, have an absence of signs/symptoms of lung cancer, have a 
tobacco smoking history of at least 20 pack-years, must be a current or former smoker who has quit in the last 
15 years, and have an order for a lung cancer screening with LDCT.   
 
We looked at the file and Medicare rules. The documentation shows a diagnosis code of Z12.2, defined as 
encounter for screening for malignant neoplasm of respiratory organs. There is no evidence in the record or 
from this diagnosis code that the enrollee is currently a smoker with a 20 pack-year history or is a former 
smoker with a 20 pack-year history that has quit within the last 15 years. Based on this information, we decided 
that Medicare rules for coverage of code 71271 have not been met. Therefore, we decided that the Plan does 
not have to pay for code 71271, defined as computed tomography, thorax, low dose for lung cancer screening, 
without contrast material(s) performed on February 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services described by codes 99053, 93010 and 
99291 for the date of service December 27, 2022. 
 
You asked the Plan to pay for codes 99053, 93010, and 99291. You say that codes 99053, 93010, and 99291 
should be paid as billed because they are supported in the documentation. The Plan denied your request. The 
Plan says code 99053 is denied because it has a Status Indicator of B, therefore it not separately payable. The 
Plan says codes 93010 and 99291 are denied because they are not supported in the documentation.  
 The Plan must follow Medicare rules. The rules say that the information submitted by the supplier or provider 
must corroborate the documentation in the enrollee's medical documentation and confirm that Medicare 
coverage criteria have been met. The rules say that for codes with a Status Indicator of B, no separate payment 
is ever made.  
 
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 code 99291. Our coder says that code 99291, defined as 
critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes, is 
not supported in the documentation. Our coder found the record does not state that critical care was provided 
for any amount of time. There is no documentation of time spent performing critical care. 
 
We looked at this coder's review, the file, and Medicare rules. Due to its Status Indicator of B, code 99053, 
defined as service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service, 
is not separately payable. Code 93010, defined as Electrocardiogram, routine with at least 12 leads; 
interpretation and report only, is not supported because there is no electrocardiogram report included in the 
documentation. Our coder found that 99291 is not supported in the documentation because the record does not 
state that critical care was provided for any amount of time. Based on this information, we decided that 
Medicare rules for coverage of codes 99053, 93010, and 99291 have not been met. Therefore, we decided that 
the Plan does not have to pay for physician services described by codes 99053, 93010 and 99291 for the date of 
service December 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve the continued SNF care. You say that it's medically necessary for the 
enrollee to continue the SNF care. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for continued SNF 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 the 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the continued skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy (45378, 45380) to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve a colonoscopy with an out-of-network (OON) provider. . You say that you 
want the Plan to approve the services. The Plan denied your request. The Plan says medically necessary 
services are available in-network, and there are no extenuating circumstances making it medically necessary to 
obtain the service out-of-network. 
 
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 
a colonoscopy (45378, 45380) to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission provided from March 11, 2023, to 
March 12, 2023. 
 You asked the Plan to pay for the inpatient admission. You say that there is no basis for the denial of inpatient 
services. You also say that as reflected in the medical record, the enrollee's care was medically justified as 
inpatient. 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient admission provided from March 11, 2023, to March 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a cervical facet joint injection. 
 
You asked the Plan to pre-approve the injection. You say that your doctor has performed two surgeries on you 
in the past and has recommended this block. The Plan denied your request. The Plan says a cervical facet joint 
injection 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 injection. Our reviewer says that the 
enrollee does not meet the LCD coverage criteria. Our physician reviewer found that the LCD requires two sets 
of diagnostic MBB's which produces 80 % pain relief. This has not been performed. Therefore, the request is 
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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cervical facet joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
segmented pneumatic appliances (E0667 and E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says records do not show that the enrollee completed a four-
week trial of regular, daily, multiple-hour home usage of the E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmented pneumatic appliances (E0667 and E0656).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307 and G0483 billed for date of service 
February 28, 2023. 
 
You asked the Plan to pay for the billed services. You say that the results determine the effectiveness of the 
treatment plan. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
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 80307 is presumptive drug testing. The definition of code 
G0483 is definitive drug testing of 22 or more drug classes. 
 
 We find that CPT codes 80307 and G0483 are not supported in the medical record. The records do not include 
the results of presumptive testing. The records do not show that the testing of 22 or more drug classes were 
provided. 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 codes 80307 and G0483 
billed for date of service February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 19, 2023, billed with 
procedure code 64488-59. 
 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 payment for this code is included in payment for 
the primary procedure. 
 
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 64488-59 is a column II code to column I code 00840; however, 
64488-59 was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the practitioner services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the record does not state that the nerve 
block was given at the surgeon's request for postoperative pain management, which is required by CPT 
guidelines in order to separately report the nerve block. 
 
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 April 19, 2023, billed with procedure code 
64488-59.