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

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on February 11, 2022. 
 
You asked the Plan to pay for the CT of the head or brain. You say that the enrollee had multiple exams on the 
date in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on February 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no prior treatment for gastroesophageal junction (GEJ) cancer. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the requested drug is 
not Food and Drug Administration (FDA) approved for first-line monotherapy. Off-label support exists for 
PDL1 high tumors, but this patient has a PDL1 low tumor (1%). The service is not reasonable or 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested procedure fills a 
treatment gap for patients that do not receive adequate relief from traditional conservative methods and don't 
have instability to indicate fusion is the appropriate treatment. You say that the enrollee has tried and failed 
conservative treatment without relief. The Plan denied your request. The Plan says the requested service is not 
widely used and not generally accepted for the suggested use as reported in nationally recognized peer-
reviewed medical literature. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental for low back pain. More research is needed. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the pelvis provided on December 3, 2021. 
 
You asked the Plan to pay for the x-ray. You did not provide a specific argument with your appeal request. The 
Plan denied your request. The Plan says the patient was enrolled in hospice on the date of service in question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the x-ray of the pelvis provided on December 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
9, 2021 to May 15, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not billed per Medicare 
guidelines. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
was not submitted with the required Q, G or revenue codes. Therefore, we decided that the Plan does not have 
to pay for the home health services provided to the enrollee from May 9, 2021 to May 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on September 15, 
2021. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were previously processed and paid by the 
Plan. 
 
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 find that CPT code 71045 is not supported in the medical record. Specifically, the documentation does not 
indicate that three separate services were performed. The documentation submitted shows there are two 
different chest x-ray reports rendered by the same provider. The documentation does not support additional 
services were completed. Based on this information, we decided that Medicare rules for coverage of the x-ray 
services have not been met.  
  
Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on 
September 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on January 10, 2022. 
 
You asked the Plan to pay for the CT of the head or brain. You say that the enrollee had multiple exams on the 
date in question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) 
Procedure to Procedure (PTP) edit exists between 70496 and 70450. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with 
this PTP code edit. This service was not billed appropriately by Medicare coding regulations. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for computed tomography (CT) of the head or brain (70450) 
provided on January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150) provided February 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87150) provided February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis provided on June 8, 
2021. 
 
You asked the Plan to pay for the targeted genomic sequence analysis. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the testing rendered included testing for 
the FANCC gene. Panels that include this gene are not covered. Based on this information, we decided that 
Medicare rules for coverage of the targeted genomic sequence analysis have not been met. 
 
 
 
  Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis provided 
on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging with single photon 
emission computed tomography (SPECT). 
 
You asked the Plan to pre-approve the imaging. The Plan denied your request. The Plan says the request is not 
medically necessary because the member has a low pretest probability of coronary artery disease (CAD), with a 
normal electrocardiogram (EKG) and the ability to exercise, per the records. 
 
The Plan follows Medicare rules. Medicare rules say that cardiovascular stress testing with cardiac imaging is 
not considered medically reasonable and necessary if the results will not affect patient management decisions. 
 
 
 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 imaging. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found the patient has chest tightness (angina 
pectoris). A nuclear stress test with myocardial perfusion imaging (SPECT) was requested. Our reviewer found 
that a previous SPECT test was performed in 2019 showing fixed defect, ejection fraction 58%, but no 
reversible ischemia. However, the provided records show that the patient with a normal electrocardiogram and 
ability to exercise. There was no contraindication for exercise stress test to evaluate the patient's symptoms. 
Our physician reviewer also found that this request for SPECT will be considered 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 the imaging services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a myocardial perfusion imaging with single photon emission computed 
tomography (SPECT).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extremity veins (93970) provided on July 20, 
2020. 
 
You asked the Plan to pay for the duplex scan. You say that this claim was billed appropriately. The Plan 
denied your request. The Plan says this is a duplicate of another claim which has been previously paid. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules state that claims or claim lines 
which have been determined to be an exact duplicate with respect to certain elements are rejected and do not 
have appeal rights. 
 
We find that CPT code 93970 is not supported in the medical record. Specifically, the provided documentation 
includes a copy of a claim with the same service billed with the same code/modifiers by the same provider on 
the same date for the same enrollee which has previously been paid. The documentation does not support that 
the enrollee received this service twice on the date in question. Based on this information, we decided that 
Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pay for duplex scan of extremity veins (93970) provided on July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulator supplies, 2 lead, per month (A4595) 
provided on January 24, 2021, to December 24, 2021. 
 
You asked the Plan to pay for electrical stimulator supplies. You say that you are requesting reconsideration for 
the denied items. The Plan denied your request. The Plan says the enrollee is not eligible for this benefit. 
 
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 find that CPT code A4595 has a status indicator of N on the Physician Fee Schedule. This means that CPT 
code A4595 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not have to pay for 
electrical stimulator supplies, 2 lead, per month (A4595) provided on January 24, 2021, to December 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve varicose vein surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of the doppler from 2/23/22 to show the outcome of the 
venous procedure as far as asymptomatic improvement. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has undergone numerous venous treatments and it has been documented that she has 
improved. She returned for a routine visit where her only complaints are knee and ankle pain while walking. 
There is documentation that she does not have bulging varicosities and documentation regarding edema is 
inadequate; however, three months earlier she was noted to have no edema. It is documented that she has 
difficulty applying the compression stockings by herself; however, there is no documentation that alternative 
stockings such as Velcro wrap style have been provided. As there is no documentation that the patient is having 
ongoing symptoms related to her varicose veins, further vein treatments cannot be considered 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve varicose vein surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on October 15, 2021. 
 
You asked the Plan to pay for acupuncture. You say that acupuncture is medically necessary. The Plan denied 
your request. The Plan says a licensed acupuncturist is a non-covered provider type and the provider is not 
supervised by any physician, physician assistant, nurse practitioner or a clinical nurse specialist. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, a licensed acupuncturist is a non-covered provider 
type and the provider is not supervised by any physician, physician assistant, nurse practitioner or a clinical 
nurse specialist. Therefore, we decided that the Plan does not have to pay for acupuncture provided on October 
15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) provided November 29, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids provided OON. You say that you chose this provider because of 
the quality of service, and you would like some level of reimbursement. The Plan denied your request. The 
Plan says the hearing aids are not covered because they were provided OON. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a provider in the Plans hearing network. 
 
We looked at the file and the Plan's rules. In this case the hearing aids were purchased OON. Based on this 
information, we decided that the Plan's rules for coverage of the hearing aids provided OON have not been met. 
Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) provided November 29, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99203) provided on December 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported.  
 
We looked at the file and Medicare rules. In this case, more than one E&M code was reported by the same 
provider on the same date of service. As one E&M code has already been paid by the Plan, the requested code 
is not payable. 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 the services (99203) provided on 
December 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a thoracentesis for aspiration of the pleural space (32555) 
provided on November 10, 2021. 
 
You asked the Plan to pay for a thoracentesis procedure. You say that the procedures at issue were separate and 
distinct. The Plan denied your request. The Plan says rules for payment have not been met because the CPT 
code at issue is inclusive to another billed code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 32555 
is a column II code to column I code 32562. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a thoracentesis for aspiration of the pleural space (32555) 
provided on November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block for the right knee. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you have knee pain. The Plan 
denied your request. The Plan says the requested service is 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 genicular nerve block. Our reviewer 
says that the requested genicular nerve block is not considered medically reasonable and necessary in this case. 
Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain including but not 
limited to osteoarthritis of the knee or as a treatment for individuals who are not candidates for knee 
replacement surgery. Therefore, the reviewer found that the requested genicular nerve block of right knee is not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a genicular nerve block for the right knee.