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

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (81455) 
provided January 4, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you performed the services at the request of 
an in-network physician and specimen was directed to your laboratory without direct involvement from the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the medical necessity 
guideline requirements. 
 
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 pay for the laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that the enrollee has several years of mild low white blood cell 
count and mild anemia. Blood tests in December showed close to normal results and a normal blood smear 
pathology assessment. The enrollee's bone marrow biopsy in December 2021 was completely normal and 
showed no signs of any kind of myeloid neoplasm. The results were sufficient to establish that the enrollee 
does not have a myeloproliferative neoplasm and, therefore, had no need for additional genetic tests like the 
NeoTYPE Myeloid Disorders Profile. The review has determined that the records do not show that the service 
is medically necessary 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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, 
DNA analysis, and RNA analysis when performed, 51 or greater genes (81455) provided January 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight additional physical therapy visits. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that additional physical therapy services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. 
Our physician reviewer found that you have had multiple therapy sessions since at least October 2021. The 
issue is chronic and you have been minimally responsive to skilled therapy. You have stabilized with therapy 
and may continue with a home exercise program. 
 
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 eight additional physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home therapy services (97110) provided on October 22, 
2021. 
 
You asked the Plan to pay for the therapy services. The Plan denied your request. The Plan says there is a more 
appropriate code for this service. 
 
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 97110 is "Therapeutic procedure, 1 or more areas, each 
15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility". 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, there is a more appropriate 
code to be used for the requested home therapy services. Based on this information, we decided that Medicare 
rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have 
to pay for the home therapy services (97110) provided on October 22, 2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 75625. We decided that the Plan does not have to pay 
for procedure code 75716.  
 
You asked the Plan to pay for procedure codes 75625 and 75716. You say that the medical records support the 
denied procedures, and the procedures should be processed for payment. The Plan says that procedure code 
75625 is not supported by the medical records submitted. The Plan also says procedure code 75716 is 
considered inclusive to procedure code 37227. 
 
We decided that the Plan has to pay for procedure code 75625.  
 
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 to pay for procedure code 75625. Our reviewer says that the documentation 
supports the use of procedure code 75625. Therefore, we decided that the Plan has to pay for procedure code 
75625. 
 
We also decided that the Plan does not have to pay for procedure code 75716. 
 
In this case, we have confirmed that code 75716 is a column II code to column I code 37227; however, 75716 
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 procedure code 75716. Our reviewer says that the medical 
documentation does not support the use of procedure code 75716 as the code description is inclusive to 
procedure code 37227. Therefore, we decided that the Plan does not have to pay for procedure code 75716. 
 
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 service, basic life support, non-emergency 
transport (A0498, A0425). 
 
You asked the Plan to pre-approve ambulance service, basic life support, non-emergency transport. You say 
that ambulance transportation with a two-person wheelchair assist is necessary for the member to go back and 
forth to dialysis treatment. The Plan denied your request. The Plan says the member does not meet medical 
necessity criteria for non-emergency ambulance transportation under Medicare or Medicaid. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service, basic life support, 
non-emergency transport. Our reviewer says that ambulance service, basic life support, non-emergency 
transport is not medically necessary. Our physician reviewer found based on the documentation provided, 
transportation via ambulance to and from hemodialysis is not medically necessary. The enrollee does not 
require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Transportation can be provided by other means (stretcher van, wheelchair van, 
private car, taxi) without endangering the enrollees condition. A prudent layperson would not believe that 
immediate medical attention was required for scheduled appointments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pre-approve ambulance service, basic life support, 
non-emergency transport (A0498, A0425).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 93042 is bundled into 
payment for code 92950. 
 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 93042 
is a column II code to column I code 92950. 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 93042 billed for date of service March 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service February 15, 
2022. 
 
You asked the Plan to pay for procedure code 74176. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 74176 is bundled into payment for code 74177. 
 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 74176 
is a column II code to column I code 74177. 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 74176 billed for date of service February 15, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit on April 29, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 
copayment for emergency room services in an in-network emergency room.  
 
 
 
 
 
 
 
 You have been asked to pay $65 for an emergency room visit. An emergency room visit falls within the 
Emergency Care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
visit on April 29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (81479) provided January 25, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says that SelectMDx testing is investigational and non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the genetic testing. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee had a Prostate-Specific Antigen (PSA) of 11.1. Research shows that men identified by the 
test as having a high likelihood of clinically significant cancer can, upon biopsy, be diagnosed and treated 
sooner, while men identified at very low risk may avoid biopsy. The SelectMDx test performed was 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 genetic testing have been met. Therefore, we decided that the Plan has to 
pay for genetic testing (81479) provided January 25, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 4, 2022, 
to April 5, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that this enrollee was admitted from the 
emergency room due to gastric hemorrhage, and notification was given to the Plan at the time of admission. 
The Plan denied your request. The Plan says the service was not authorized. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found based on the enrollee only requiring an esophagogastroduodenoscopy 
(EGD) for likely gastric ulcer, blood transfusion, and fluids administration, it was not expected that the enrollee 
would require hospital services that would likely cross 2 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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from April 4, 2022, to April 5, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 an epidural steroid injection. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician 
reviewer found the clinical documentation is insufficient to demonstrate that the coverage criteria, as 
established by LCD L39036 have been met in this case. It is not documented that a different approach, level, 
and/or medication is/are to be used in this case. The rationale and medical necessity are not sufficiently 
documented. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous transcatheter placement of intracoronary 
stents, with coronary angioplasty when performed, single major coronary artery or branch (92928) for the 
enrollee. 
 
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 records do not show that the enrollee has an isolated left main 
disease, nor the enrollee's syntax score is less than 33. 
 
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 enrollee has 
triple-vessel coronary artery disease. Guidelines do not support the use of percutaneous coronary intervention 
(PCI) of the left main coronary artery (LMCA) unless the LMCA stenosis is isolated, and the SYNTAX score 
is less than 33. The SYNTAX score is not documented. As a result, at this time PCI of the left main coronary 
artery would not be considered medically appropriate and necessary in this enrollees clinical management. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  
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 percutaneous transcatheter placement of intracoronary stents, with coronary angioplasty 
when performed, single major coronary artery or branch (92928) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29827 billed for date of service January 12, 
2022. 
 
You asked the Plan to pay for procedure code 29827. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 29827 is bundled into payment for code 29821.  
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 29827 
is a column II code to column I code 29821. 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 29827 billed for date of service January 12, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services rendered on October 1, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99239 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
 
 
 
 
 
 
 We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 
hospital discharge day management of more than 30 minutes. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the hospital discharge services rendered on October 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with Multiple Power 
Options (K0861), a power tilt and recline (E1007), and other accessories (E2300, E2363, E2311, E2620, 
E1012, E0955, E1028, E0960, E1028, E2377, E2313, E2323, E1029, E2607). 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with Multiple Power Options, a power tilt and 
recline, and other accessories. You say that this is medically necessary. The Plan denied your request. The Plan 
says this exceeds the enrollee's needs. 
 The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with Multiple Power 
Options (K0861) is covered if the beneficiary's mobility limitation is due to a neurological condition, 
myopathy, or congenital skeletal deformity; and the beneficiary either uses a ventilator or meets coverage 
criteria for a power tilt and recline seating system. A power seating system will be covered if the beneficiary is 
at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or the 
beneficiary utilizes intermittent catheterization. 
 
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 a Group 3 power wheelchair with 
Multiple Power Options, a power tilt and recline, and other accessories. Our reviewer says that the specific 
requested wheelchair is not medically necessary. Our physician reviewer found the enrollee does not use a 
ventilator or intermittent catheterization and is not at high risk for skin breakdown. He can weight shift as he 
can self-transfer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 power wheelchair with Multiple Power Options, a power tilt and 
recline, and other accessories have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Group 3 power wheelchair with Multiple Power Options (K0861), a power tilt and recline (E1007), 
and other accessories (E2300, E2363, E2311, E2620, E1012, E0955, E1028, E0960, E1028, E2377, E2313, 
E2323, E1029, E2607).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure coded as 64628 and 64629. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that you would like to appeal the denial of 
prior authorization for the procedure that you need done on your back. The Plan denied your request. The Plan 
says there is not enough studies to show it is safe and effective. 
 
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 the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Intracept procedure coded as 64628 and 64629.