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

 
We decided that the Plan does not have to pay for the medical services coded 22612, 22614 and 22846 
provided from April 20, 2022, through April 21, 2022. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the medical records submitted do not 
support the services 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 22612 is arthrodesis, posterior or posterolateral 
technique, single interspace; lumbar (with lateral transverse technique, when performed). The CPT Code 
Manual definition of code 22614 is arthrodesis, posterior or posterolateral technique, single interspace; each 
additional interspace (List separately in addition to code for primary procedure). The CPT Code Manual 
definition of code 22846 is anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to 
code for primary procedure).  
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the medical services. Our reviewer says that the 
documentation does not support payment for the CPT codes as billed. Our reviewer found the operative report 
documents the following: "The endplate was prepared with a rasp. We went through a series of trials and 
ultimately chose a 10 mm tall x 22 mm wide x 60 mm long cage... We packed some Osteocel into the leading 
edge of the annulotomy, and then the cage was tapped into position and appeared to be well positioned... There 
was a nerve crossing my field, so I did not feel like I could get a 22 mm cage, and this had excellent 
interference fit. We placed an 18 mm wide, 55 mm long, 10 mm cage, and this had excellent interference fit." 
In this case, a separate plate that spans the interspace to provide independent stabilization cannot be verified in 
the operative report. Therefore, it would not be reported separately.  
 
In addition, the operative report goes on to describe the following, "We underwent an anterior lumbar interbody 
fusion at L4005 and L5-S1." In this case, the arthrodesis procedures are not accurately described in the 
operative report and therefore cannot be verified for payment. 
 
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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services coded 22612, 22614 and 22846 provided from April 20, 2022, 
through April 21, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee joint replacement surgery to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve knee joint replacement surgery to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
knee joint replacement surgery 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 the services provided on January 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on February 24, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the services have not been met.  
 
 
 
  
 
Therefore, we decided that the Plan does not have to pay for the services provided on January 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Oncology (urothelial), mRNA, gene expression profiling by 
real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing 
urine, algorithm reported as a risk score for having urothelial carcinoma (0012M) provided April 18, 2022. 
 
You asked the Plan to pay for CXbladder Detect test. You say that you disagree with this decision and 
appreciate prompt review of this information and authorization of coverage for the CXbladder Detect test for 
this enrollee. The Plan denied your request. The Plan says the CXbladder panel remains unproven at this time 
and is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CXbladder Detect test have not been met. Local Coverage Determination (LCD) Biomarkers for 
Oncology L35396 also says non-coverage reaffirmed for CPT codes 0012M and 0013M for CxBladder. 
Therefore, we decided that the Plan does not have to pay for Oncology (urothelial), mRNA, gene expression 
profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), 
utilizing urine, algorithm reported as a risk score for having urothelial carcinoma (0012M) provided April 18, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Factor II (F2) gene testing. 
 
You asked the Plan to pre-approve F2 gene testing. You say that this testing is medically necessary to 
determine if the enrollee has the mutation for increased risks for future thrombosis. The Plan denied your 
request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that F2 genetic testing is not medically necessary and 
is not covered by Medicare.  
 
We looked at the file and Medicare rules. This testing is not covered by Medicare. Based on this information, 
we decided that Medicare rules for coverage of F2 gene testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Factor II (F2) gene testing.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on December 16, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you would like the claim to be processed 
for payment. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no approved authorization. Also, the service rendered was not urgent or emergent. 
  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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility care provided on December 16, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF care to facilitate increased 
independence and return home and to the community with an improved quality of life. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity angiography and revascularization of 
bilateral iliac arteries. 
 
You asked the Plan to pre-approve lower extremity angiography and revascularization of bilateral iliac arteries. 
You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that vascular stents are used to enhance primary patency 
in arteries and veins, usually at the site of stenotic or occlusive lesions. Stents also may be used as an adjunct to 
technically inadequate Percutaneous Transluminal Angioplasty (PTA) or in cases where PTA alone will not be 
expected to provide a durable result. 
 
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 lower extremity angiography and 
revascularization of bilateral iliac arteries. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found there is insufficient documentation to support the medical necessity for lower 
extremity angiography and revascularization of bilateral iliac arteries in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity angiography and revascularization of bilateral iliac arteries 
have not been met. Therefore, we decided that the Plan does not have to pre-approve lower extremity 
angiography and revascularization of bilateral iliac arteries.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the items are necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 4, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
complete lower denture (D5120).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR).  
You asked the Plan to pre-approve insertion of an ILR. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found while you have a history of atrial 
fibrillation, there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke 
or any other apparent indication for an ILR. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR in your clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says based on 
Medicare guidelines and the information we have about the enrollee's condition they do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to an acute inpatient hospital on September 2, 2022, with a 
perforated gastric ulcer and sepsis. The enrollee is currently on trach collar with twenty-eight percent FiO2 in 
the day, with ventilator support at night. There is no documentation provided indicating medical necessity for 
admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug test(s), presumptive, any number of drug classes, any 
number of devices or procedures; by instrument chemistry analyzers (80307) billed for date of service April 26, 
2022. 
 
You asked the Plan to pay for drug tests. You say that these services are supported as billed. The Plan denied 
your request. The Plan says another provider billed code 80305 for this enrollee for the same date of service. 
Additional reimbursement is not warranted for more than one presumptive urine drug test per patient per date 
of service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will only pay for one presumptive test 
result per patient per date of service regardless of the number of billing providers.  
 
We looked at the file and Medicare rules. The record shows that the Plan has already paid for a presumptive 
urine drug test (80305) for this enrollee for the date in question. Based on this information, we decided that 
Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by 
instrument chemistry analyzers (80307) billed for date of service April 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77081 billed for date of service April 11, 
2022. 
 
You asked the Plan to pay for procedure code 77081. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 77081 is bundled into payment for 
code 77080. 
 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 77081 
is a column II code to column I code 77080. 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 77081 billed for date of service April 11, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from July 2, 2021, to July 21, 
2021. 
 
You asked the Plan to pay for home health services. You say that your submission of the RAP for the period of 
care at issue was untimely due to an undeclared change in the enrollee's insurance. The Plan denied your 
request. The Plan says rules for payment for home health services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the RAP must be submitted within five calendar 
days after the start of care for home health services. 
 
We looked at the file and Medicare rules. The services were not supported in this case as there is no evidence 
that a valid RAP was submitted timely for the home health services at issue in this case. Based on this 
information, we decided that Medicare rules for coverage of home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided from July 2, 2021, 
to July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Bortozemib injections provided on June 
03, 2021. 
 
You asked the Plan to waive the coinsurance for Bortozemib injections. You say that you are on a fixed income 
and cannot afford this 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 Bortozemib injections. 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.  Therefore, we decided that the Plan does not have to waive the coinsurance for 
Bortozemib injections provided on June 03, 2021.
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 these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this service is considered experimental and investigational. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Intracept 
procedure is experimental. More research is needed. Our physician reviewer found that your condition does not 
meet criteria for coverage of the Intracept procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure.