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

 
We decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided on June 23, 
2022. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed.  
We find that CPT code G0483 is not supported in the medical record. Specifically, the medical records 
submitted do not include laboratory results of 22 or more drug class(es) tested. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing (CPT code G0483) provided on June 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoperative neurological monitoring (IONM) provided 
on March 15, 2022. 
 
You asked the Plan to pay for the IONM. You say that the services were medically necessary for the enrollee. 
The Plan denied your request. The Plan says the IONM for an anterior cervical discectomy fusion (ACDF) 
surgery without spinal cord compression 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 pay for the IONM. Our reviewer says that the 
requested IONM is not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on current literature it cannot be determined that the services provided were the most appropriate 
level of service or supply that could have been provided to the enrollee. Therefore, the reviewer found that the requested service is not 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 IONM have not been met. Therefore, we decided that the Plan does not have 
to pay for the intraoperative neurological monitoring (IONM) provided on March 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours per week of home health aide (HHA) 
services. 
 
You asked the Plan to pre-approve additional hours per week of HHA services. You say that you have 
dementia and a bad leg. You also say that you weigh 300 pounds, and it is hard for you to do things. The Plan 
denied your request. The Plan says you only require 5.5 hours per week of HHA services. 
 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 per week of HHA 
services. Our reviewer says that additional hours per week of HHA services are not medically reasonable and 
necessary. Our physician reviewer found you do not have documented skilled nursing needs. Our reviewer 
found that you do not have documented skilled therapy needs. Our physician reviewer also found that there is 
no evidence that HHA services are required to assist in the treatment of an illness or injury. 
 
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 per week of HHA services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional hours per week of home health aide (HHA) 
services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transportation provided on May 25, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the non-emergency transportation. You say that you would like a retro 
authorization and for the claim to be reimbursed. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no approved authorization. 
 
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 non-emergency transportation provided on 
May 25, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services coded 51702, 71250, 72125, 72128, 72131, 
73130, 74176, and 93005 provided on February 17, 2022. 
 
You asked the Plan to pay for the services coded 51702, 71250, 72125, 72128, 72131, 73130, 74176, and 
93005. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services billed are 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 CPT code. 
 
We find that CPT codes 51702, 71250, 72125, 72128, 72131, 73130, 74176, and 93005 are not supported in the 
medical record. Specifically, payment for these codes is packaged into the ambulatory payment classification 
(APC) rate. This means these codes are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the services coded 51702, 71250, 72125, 72128, 72131, 73130, 74176, and 93005 have not been met. Therefore, we decided that the Plan does not have to pay for the services coded 
51702, 71250, 72125, 72128, 72131, 73130, 74176, and 93005 provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 20, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided on July 20, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pacemaker. 
 
You asked the Plan to pre-approve a pacemaker. You say that the records provided support the need for the 
requested device. The Plan denied your request. The Plan says the requested device is not currently indicated 
because the enrollee does not have symptoms related to bradycardia, higher grade AV block, or significant 
sinus pauses. 
 
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 a pacemaker. Our reviewer says that a 
pacemaker is not considered medically reasonable and necessary in this case. Our physician reviewer found 
while the enrollee has a history of incomplete right bundle branch block, coronary artery disease and stroke, 
there is no documentation of symptomatic bradycardia. As such, there is insufficient documentation to support 
the medical necessity for insertion of a pacemaker 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 a pacemaker have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pacemaker.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. You say that this is the second request for the left 
side. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications.  
 
 
 We looked at the file and Medicare rules. The records show that the enrollee has had two radiofrequency 
sessions in the lumbar region within the last 12 months. Based on this information, we decided that Medicare 
rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 20, 
2021, to August 23, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that medical necessity for the need for 
the services provided and billed is supported. The Plan denied your request. The Plan says the information 
received does not support that criteria were met for an inpatient hospitalization. 
 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 the enrollee presented to the emergency department with fall, striking head 
on their way to hemodialysis. Evaluation showed the enrollee was awake but confused to time. Vitals were 
stable and the enrollee was not in any acute distress. Our reviewer found that the examination was 
unremarkable, and imaging only showed chronic small vessel disease, but no acute findings. The enrollee was 
admitted, and their condition improved with observation and was switched to inpatient without evidence of any 
worsening condition but was awaiting sub-acute rehabilitation placement. Our physician reviewer also found 
that based on this low complexity, low severity presentation, it was not expected that the enrollee would require 
inpatient 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 August 20, 2021, to August 
23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested procedure is not significantly different in access risk than the diagnostic 
injections. 
 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee has chronic axial cervical pain without radiculopathy. The record indicates 
that the enrollee has had two successful diagnostic medial blocks. The record does not indicate new onset 
symptoms, injury or neurologic examination abnormalities. The record indicates that the enrollee has had a 
cervical MRI in June 2021 that demonstrated disease at C3-C4 and C4-C5. The record does not indicate a 
change in clinical condition since that time. The requested service is not medically necessary and reasonable 
for the diagnosis and treatment for the enrollee's clinical condition at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastrointestinal (GI) tract capsule endoscopy. 
 
You asked the Plan to pre-approve a GI tract capsule endoscopy. You say that you feel this is medically 
necessary because your provider told you there may be blood, and regular endoscopies are not sufficient 
enough to find it. The Plan denied your request. The Plan says the criteria is not met because there is no 
documented evidence of obscure gastrointestinal bleeding or unexplained iron deficiency anemia. 
 
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 a GI tract capsule endoscopy. Our 
reviewer says that a GI tract capsule endoscopy is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that you had iron deficiency anemia that has resolved 
with treatment. A colonoscopy was noted to be normal in 2020, and a recent upper endoscopy demonstrated 
resolved gastritis and esophageal stricture. Our reviewer found that the record does not demonstrate the 
presence of gastrointestinal bleeding. Our physician reviewer also found that the record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 
 
 
 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 GI tract capsule endoscopy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a gastrointestinal (GI) tract capsule endoscopy.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve therapy services. You say that your provider submitted medical records to 
the Plan. The Plan denied your request. The Plan says that the requested therapy is 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 therapy services. Our reviewer says that 
the coverage criteria has been met. Our physician reviewer found that you have chronic radiculopathy, which is 
treated with physical therapy. The Plan has not provided a rationale for the denial consistent with Medicare 
rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapy services have been met. Therefore, we decided that the Plan has to pre-
approve physical therapy services.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glasses (V2797) provided on July 11, 2022, by a non-
Medicare eligible provider. 
 
You asked the Plan to pay for the glasses. You say that the company you purchased your glasses from will not 
bill your insurance company, and you would like to be reimbursed for them. The Plan denied your request. The 
Plan says this service is not a covered benefit. 
 
The plan must follow Medicare rules. The rules say that services must be provided by providers who are 
enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the glasses have not been met. Therefore, we decided that the Plan does not have to pay for the 
glasses (V2797) provided on July 11, 2022, by a non-Medicare eligible provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast cancer gene (BRCA) testing. 
 
You asked the Plan to pre-approve BRCA testing. 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 BRCA testing is 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 BRCA testing. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no documentation of any signs 
or symptoms of cancer. In the genetic counseling documentation, you were advised that you did not qualify for 
BRCA per NCCN guidelines. The review has determined that you do not meet the coverage criteria detailed in 
the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BRCA testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve breast cancer gene (BRCA) testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 17, 2022, billed with 
codes 81291, 0031U, 0032U, 81225, 81227, 81230, 81231 and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
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 
May 17, 2022, billed with codes 81291, 0031U, 0032U, 81225, 81227, 81230, 81231 and 81355.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve open magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says they were unable to reach the Primary Care Physician to get an order. 
 
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 the MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that in this case, the 
record indicates that the enrollee suffered a fall in September 2022 that resulted in a concussion. The record 
indicates the enrollee continues to have headaches and light sensitivity and may have post-concussion 
syndrome. The record indicates that the enrollee has a normal neurologic examination. The record indicates 
that the enrollee has had a computed tomography (CT) scan that demonstrated chronic microvascular changes 
and cerebral atrophy. The record indicates that the enrollee is referred to a neurologist. The requested service is 
not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at 
this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve open magnetic resonance imaging (MRI).