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

 
We decided that the Plan does not have to pay for the duplex scan of arterial inflow and venous outflow of 
abdominal, pelvic, scrotal contents and/or retroperitoneal organs (93975) provided on June 14, 2022. 
 
You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says this service is not 
covered. 
 
The Plan follows Medicare rules. Medicare rules say that the indications for abdominal/visceral non-invasive 
vascular studies are listed in the Medicare rules section of this letter. 
 
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 duplex scan. Our reviewer says that the 
enrollee did not meet the criteria for coverage for the duplex scan. Our physician reviewer found the enrollee 
does not have a condition which is indicated for coverage that is listed in the local coverage determination. 
 
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 duplex scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents 
and/or retroperitoneal organs (93975) provided on June 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection, major joint or 
bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610) Low osmolar contrast 
material, 300-399 mg/ml iodine concentration, per ml (Q9967) and Injection, methylprednisolone acetate, 40 
mg (J1030) provided March 24, 2021. 
 
You asked the Plan to pay for the ambulatory surgery services. You say that you are requesting that the claims 
are reconsidered for processing as this timely issue was out of your hands. The Plan denied your request. The 
Plan says the claim was submitted past the timely filing limitation 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulatory surgery services was not filed until May 18, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610) Low osmolar 
contrast material, 300-399 mg/ml iodine concentration, per ml (Q9967) and Injection, methylprednisolone 
acetate, 40 mg (J1030) provided March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 4, 2022 billed with 
codes 0031U, 0032U, 81225, 81227, 81230, 81231, 81291, 81328, 81355 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed fro 
medical necessity. The Plan denied your request. The Plan says this claim has not been billed as required by 
Medicare billing regulations. 
 
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 the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 4, 2022 billed with codes 0031U, 0032U, 81225, 81227, 81230, 81231, 81291, 81328, 81355 and 81479.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lower extremity other 
than joint (73718). 
 
You asked the Plan to pre-approve an MRI of the lower extremity other than joint. The Plan denied your 
request. The Plan says that this MRI cannot be considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve an MRI of the lower extremity other 
than joint. Our reviewer says that an MRI of the lower extremity other than joint is reasonable and necessary. 
Our physician reviewer found the enrollee has persistent right great toe pain, with abnormal x-rays showing 
possible bone cyst, pes planus deformity, and hammertoes of the right foot. Our reviewer also found that these 
are criteria which will not be addressed with physical therapy, and provide valid indications for the requested 
MRI. 
 
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 MRI of the lower extremity other than joint have been met. Therefore, we 
decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lower extremity other than 
joint (73718).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve the SCS. You say that without the requested procedure you will be unable to 
walk due to the severe pain. You say that you are unable to sleep due to the pain. You say that you do not want 
to be wheelchair bound. The Plan denied your request. The Plan says the request is not medically necessary 
because the records show that the enrollee has had a trial stimulator placed that showed an improvement in pain 
and function. 
 
The Plan follows Medicare rules. Medicare rules say that an SCS is covered for certain medical indications. 
 
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 SCS. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the documentation does not support that 
the enrollee in this case has undergone careful screening, evaluation and diagnosis by a multidisciplinary team 
prior to implantation. There is no documentation of a positive response to an SCS trial. 
 
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 SCS have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a spinal cord stimulator (SCS).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 24, 2022 billed with 
codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, 81311, and 81321. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
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 the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 24, 2022 billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, 81311, and 
81321.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laser therapy services provided on February 16, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee has symptomatic rosacea. The 
Plan denied your request. The Plan says no photographs were submitted for review. 
 
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 17108 destruction of cutaneous vascular proliferative 
lesions (e.g., laser technique); over 50.0 sq cm. We find that CPT code 17108 is not supported in the medical 
record. Specifically, there is not enough clinical documentation to show that the procedure was medically 
necessary and not cosmetic. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the laser 
therapy services provided on February 16, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says an IRF admission does not meet the Medicare coverage criteria. 
 
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. The enrollee was admitted for a rib fracture. The enrollees medical problems are stable. There are no complex 
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a 
reasonable expectation that this 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need help with your speech and walking. The 
Plan denied your request. The Plan says the Medicare guidelines for IRF admission was not met and the 
enrollee's medical needs can be taken care of at a lower level of care like a skilled nursing facility. 
 
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 enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times a week in an IRF. There are no acute rehabilitation nursing needs 
identified or documented. At the current functional level, the enrollee does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. 
 
The documentation does not support necessity for admission to an IRF due to lack of medical complexity, lack 
of rehabilitation nursing needs and high functional status. While the enrollee may benefit from physical therapy 
and occupational therapy, the enrollee's rehabilitation needs can be provided in a lower intensity and alternate 
setting such as in in-home with 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 18, 2021, billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81355, 81381, 81240, 81241, 81283, 81328, 81335, and 
81350. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the claim 
was billed incorrectly. 
 
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 the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 18, 2021, billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81355, 81381, 81240, 81241, 
81283, 81328, 81335, and 81350.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours of home health aide (HHA) services 
(T1021). 
 
You asked the Plan to pre-approve additional hours of HHA services. The Plan denied your request. The Plan 
says this request is not considered medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 additional hours of HHA services. Our 
reviewer says that additional HHA hours are not reasonable and necessary. Our physician reviewer found there 
is no documentation that the HHA services are reasonable and necessary for the treatment of your illness or 
injury by the skilled professional staff. Our reviewer also found that the records do not document a medical 
necessity for four hours per day, 7 days per week, of HHA services as opposed to the health plan's approved 
HHA services of three hours per day, 5 days per week. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional hours of HHA services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional hours of home health aide (HHA) services (T1021).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint fusions. 
 
You asked the Plan to pre-approve SI joint fusions. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SI joint fusions. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has previous lumbar fusion. There is no SI joint instability, fracture, or lesion. SI 
joint fusion or degenerative back pain is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint fusions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac (SI) joint fusions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99024 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 99024. The Plan denied your request. The Plan says procedure 
code 99024 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99024 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99024 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99024 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99024 billed for date of service May 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says LTACH services are not 
medically necessary. There are no required medical services in LTACH that you are not already receiving in 
your current hospital setting. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you need this as soon as possible. The Plan denied 
your request. The Plan says Medicare does not cover a ventilator for the requested purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. Medicare does not cover a ventilator for the requested purpose. 
Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve use of a ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64635, 64636 x 2). 
 
You asked the Plan to pre-approve the RFA. You say that the enrollee had adequate relief from the medial 
branch blocks. You say that the enrollee was not able to complete physical therapy due to the pain. You also 
say that this is medically necessary. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a radiofrequency ablation is indicated when a patient 
has had at least two medial branch nerve blocks of the facet joints which have provided 80% or more pain relief. 
 
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 RFA. Our reviewer says that the 
requested RFA is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee had at least 80% relief with at least 2 medial branch blocks (MBBs). Therefore, the 
reviewer found that the requested RFA 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 RFA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation (RFA) (64635, 64636 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cancer and cardiac genetic panel (81201, 
81295, 81403, 81405, and 81406) provided July 1, 2021. 
 
You asked the Plan to pay for the hereditary cancer and cardiac genetic panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says screening genetic testing is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: code 80061 (Lipid panel) which includes codes: 82465 (Cholesterol, serum 
or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol), and/or 84478 
(Triglycerides). 
 
We looked at the file and Medicare rules. The codes billed for the hereditary cancer and cardiac genetic panel 
are non-covered for screening purposes. Based on this information, we decided that Medicare rules for 
coverage of the hereditary cancer and cardiac genetic panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the hereditary cancer and cardiac genetic panel (81201, 81295, 81403, 81405, and 
81406) provided July 1, 2021.