Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mastectomy sleeve. 
 
You asked the Plan to pre-approve a mastectomy sleeve. You say that this is necessary for your condition. The 
Plan denied your request. The Plan says this item is statutorily not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that a mastectomy sleeve (L8010) is denied as noncovered, since it does not 
meet the definition of a prosthesis. Therefore, we decided that the Plan does not have to pre-approve a 
mastectomy sleeve.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cervical epidural steroid (spinal) injection (62321). 
 
You asked the Plan to pre-approve the injection. You say that the services should be covered because the 
enrollee recently failed chiropractor services and anti-inflammatories. You state the enrollee had injections in 
the past with great relief. The Plan denied your request. The Plan says the epidural steroid injection requested is 
denied in that the imaging reports supplied are eight years old and do not exclude other possible causes of the 
enrollee's pain. 
 
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 physician reviewer 
found the imaging reports supplied are eight (8) years old and do not exclude other possible causes of the 
enrollee's pain. The review has determined that the medical records provided do not meet the requirements 
listed in the LCD for Medicare 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cervical epidural steroid (spinal) injection (62321).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical pathology service (88305) provided on July 27, 
2021. 
 
You asked the Plan to pay for a surgical pathology service. You say that this was a separate service. The Plan 
denied your request. The Plan says this cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the technical 
component (TC) of a physician pathology service provided to an inpatient or outpatient. 
 
We looked at the file and Medicare rules. The record shows that the service at issue was provided to a hospital 
outpatient, but this service was not billed with a modifier to indicate only the professional component, not the 
technical component, is being billed. Based on this information, we decided that Medicare rules for coverage of 
a surgical pathology service have not been met. Therefore, we decided that the Plan does not have to pay for a 
surgical pathology service (88305) provided on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) 
(78452). 
 
You asked the Plan to pre-approve the nuclear stress test. You say that the enrollee has been having chest pain. 
You also say that the enrollee needs to have a Nuclear Stress Test. The Plan denied your request. The Plan says 
the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging is indicated for 
diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by 
drugs, bundle branch block, or left ventricular hypertrophy. 
 
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 nuclear stress test. Our reviewer 
says that the nuclear stress test is not medically reasonable or necessary. Our physician reviewer found the 
provided records do not document the enrollee has chest pain and uninterpretable or equivocal 
electrocardiogram (ECG) changes caused by drugs, bundle branch block, or left ventricular hypertrophy. The 
documentation does not indicate that the requested service meets the 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 nuclear stress test have not been met. Therefore, we decided that the Plan 
does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (78452).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroscopy services coded 29824 provided on March 11, 
2022. 
 
You asked the Plan to pay for the arthroscopy services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as 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 29824 is arthroscopy, shoulder, surgical; distal 
claviculectomy including distal articular surface (Mumford procedure). 
 
We find that CPT code 29824 is not supported in the medical record. Specifically, payment for this service is 
included in the payment for another service billed on the claim. Review of the file shows that the Plan paid the 
full value of the highest paid code 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair) plus the 
difference between the next highest code 29824 and the base procedure code of 29805. Based on this 
information, we decided that Medicare rules for coverage of the arthroscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the arthroscopy services coded 29824 provided on 
March 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan billed for services provided on May 12, 
2021. 
 
You asked the Plan to pay for the services provided. You say that medical records were provided. The Plan 
denied your request. The Plan says the documentation does not support an additional study. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 93970 is duplex scan of extremity veins including 
responses to compression and other maneuvers; complete bilateral study. We find that 2 units of CPT code 
93970 were billed on the date of service at issue. The records indicate that 1 test was provided, which was 
billed and paid for by the Plan. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to further pay for the duplex scan billed for 
services provided on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the date of service is incorrect. 
 
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 81479 is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on January 11, 2022. The documentation does not support the billed date of 
service of February 10, 2022. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 21, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Review of the file shows that there is no evidence to support the referring provider was treating the enrollee for 
this testing. This means the test at issue in this appeal was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on March 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 18, 
2022. 
  You asked the Plan to pay for procedure code 70450. You say that the coding department states this is correctly 
coded. You say that the documentation should be reviewed, and the claim reprocessed for payment. The Plan 
denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
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 procedure code 70450 billed for date of service January 18, 
2022.
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 
March 14, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that claims for home health services require a valid type of 
bill for processing and payment. 
 
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, these 
services were billed with an incorrect type of bill code. Therefore, we decided that the Plan does not have to 
pay for the home health services provided to the enrollee from March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 25, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on January 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
February 18, 2021, to March 6, 2021. You asked the Plan to pay for SNF care. You say that these services were pre-approved and billed correctly. 
The Plan denied your request. The Plan says this claim was billed without a valid HIPPS rate code; therefore, 
payment cannot be made for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that all skilled nursing facility (SNF) Part A inpatient services are paid under a prospective 
payment system (PPS). This involves payment based on a Health Insurance Prospective Payment System 
(HIPPS) rate code. Under the new Patient-Driven Payment Model (PDPM), which is effective for services 
provided on or after 10/1/2019, the HIPPS code is structured differently, as a result of there being five case-mix 
adjusted rate components under the revised model. The rules also 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. We find that that the SNF claim was not submitted with sufficient 
information for payment. Specifically, the HIPPS code on this claim was entered as ZZZZZ, which is not a 
valid code. 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 pay for skilled nursing facility (SNF) services 
provided from February 18, 2021, to March 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge day management (99217) 
provided on February 13, 2022. 
 
  You asked the Plan to pay for observation care discharge day management (99217). You say that Medicare 
pays for CPT code 99217 in an outpatient setting and the clinical notes support the medical necessity. The Plan 
denied your request. The Plan says a qualifying initial or subsequent observation care service was not found in 
the enrollees claims history. 
 
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 99217 is observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.]). 
 
We find that CPT code 99217 is not supported in the medical record. Specifically, there is no evidence that an 
initial or subsequent observation service has been billed. Based on this information, we decided that Medicare 
rules for coverage of observation care discharge day management (99217) have not been met. Therefore, we 
decided that the Plan does not have to pay for observation care discharge day management (99217) provided on 
February 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 provided November 23, 2021. 
 
You asked the Plan to pay for the diagnostic laboratory service. You say that you are requesting review of the 
documents and full allowance of the list price for Guardant360 against the enrollee's in-network benefits. The 
Plan denied your request. The Plan says the criteria has not been met as the enrollee had this same exact test 
(Guardant360) for the diagnosis of prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the enrollee had this same test (Guardant360) 
for the diagnosis of prostate cancer on date of service September 23, 2021. Medicare rules says that diagnostic 
genetic testing for a disease should be performed once in a lifetime. Based on this information, we decided that 
Medicare rules for coverage of the diagnostic laboratory service have not been met. Therefore, we decided that 
the Plan does not have to pay for the Guardant360 provided November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DPYD (dihydropyrimidine dehydrogenase) gene testing 
(81232) provided on December 30, 2021. 
 
You asked the Plan to pay for DPYD testing. You say that this service is medically necessary and supported in 
the medical records. The Plan denied your request. The Plan says this service is automatically considered not 
reasonable and necessary per Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that certain codes are automatically denied as not 
medically necessary as they are unlikely to impact therapeutic decision making in the clinical management of a 
patient. 
 
We looked at the file and Medicare rules. Code 81232 is listed under the Group 3 Paragraph of Article A56199. 
This means that this service is considered automatically denied as not medically necessary. Based on this 
information, we decided that Medicare rules for coverage of DPYD testing have not been met. Therefore, we 
decided that the Plan does not have to pay for DPYD (dihydropyrimidine dehydrogenase) gene testing (81232) 
provided on December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians unlisted supplies and materials used in non-
surgical procedures provided on April 3, 2022. 
 
You asked the Plan to pay for physicians unlisted supplies and materials used in non-surgical procedures. You 
say that the services were urgently needed. The Plan denied your request. The Plan says only urgent and 
emergent services are covered under your foreign claims worldwide benefit. 
 
The Plan contract covers Worldwide Coverage. The Plan says if you have an emergency outside of the U.S. 
and its territories you are covered with a 20% coinsurance after a $100 deductible. 
 
We looked at the file and the Plans rules. The file shows that physicians unlisted supplies and materials used 
in non-surgical procedures is not covered under the Worldwide Coverage benefit. Therefore, we decided that 
the Plan does not have to pay for physicians unlisted supplies and materials used in non-surgical procedures 
provided on April 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service December 
14, 2021. 
 You asked the Plan to pay for procedure code 88342. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 88342 is bundled into payment for code 88344. 
 
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 88342 
is a column II code to column I code 88344. 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 procedure code 88342 billed for date of service December 14, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued observation services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says observation is only covered for 48 hours. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this enrollee with dementia was admitted to observation care due to increased behavioral issues at 
the long-term care facility. Extension of observation services beyond 48 hours was requested due to delays in 
placement. The recent notes described the patient as having been started on Seroquel and was stable without 
aggressive behavior and hemodynamically stable. Continued stay at an non-acute level is more appropriate and 
continued observation status is not supported beyond the 48 hours already completed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued observation services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular cancer genomics testing provided on October 26, 
2021. 
 
You asked the Plan to pay for molecular cancer genomics testing. You say that you disagree with the denial of 
the claim. You have submitted documents for further review and reconsideration of the claim payment. The 
Plan denied your request. The Plan says the requested laboratory services are non-covered as Medicare denies 
coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be 
submitted for the panel. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of molecular cancer 
genomics testing billed have not been met. Therefore, we decided that the Plan does not have to pay for 
molecular cancer genomics testing provided on October 26, 2021, billed with codes 81162, 81292, 81321, 
81407, 81408.