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

 
We decided that the Plan does not have to pre-approve Percutaneous implantation of neurostimulator electrode 
array, epidural (63650) and Implantable neurostimulator electrode (L8680) 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 evidence of adequate trials, and failure to 
respond to other treatment options. 
 
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. Detailed 
documentation is not evident regarding this being a last resort treatment. Other treatment modalities 
(pharmacological, surgical, physical, or psychological therapies) have not all been tried and/or did not prove 
satisfactory or are judged to be unsuitable or contraindicated. The documentation did not indicate that she has 
had a surgical referral/consultation that has deemed her not suitable for surgery. Additionally, the recent exams 
do not demonstrate significant objective deficits to support this request. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to 
guidelines. 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 implantation of neurostimulator electrode array, epidural (63650) and 
Implantable neurostimulator electrode (L8680) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic bilateral SI 
joint pain. He has been treated with medical therapy and spinal injections. According to the literature, sacral 
lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint 
mediated pain is considered experimental and investigational.  Radiofrequency ablation for denervation, 
whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and 
therefore, 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 these services have not been met.  
  
Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation 
(RFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear interpretation (85060) provided on January 
7, 2022. 
 
You asked the Plan to pay for the blood smear interpretation. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says this claim was not billed with the 
correct place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 85060 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 85060 has a professional/technical component indicator of 8. This indicator identifies the professional 
component of clinical laboratory codes for which separate payment may be made only if the physician 
interprets an abnormal smear for hospital inpatient.  This claim was not billed with an inpatient place of service 
code. Based on this information, we decided that Medicare rules for coverage of the blood smear interpretation 
have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear interpretation 
(85060) provided on January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the drug testing services provided on July 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on October 11, 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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is no documentation to support that the chest x-ray was 
medically necessary. 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 chest x-ray rendered on 
October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided October 5, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the testing performed is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MolDX will also deny panels of tests that include 
the FANCC gene. 
 
We looked at the file and Medicare rules. This panel included testing for the FANCC gene. Panels that include 
this testing are statutorily excluded. Based on this information, we decided that Medicare rules for coverage of 
the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic 
testing (81455) provided October 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (71045) provided on December 24, 2021. 
 
You asked the Plan to pay for an x-ray. You say that this service was performed. The Plan denied your request. 
The Plan says this is 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. In this case, we have confirmed that code 71045 is a column II code to column I code 74022, which was 
previously billed and paid. 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 an x-ray (71045) provided on December 24, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the cardiovascular testing (81479) provided on March 1, 2021. 
 
You asked the Plan to pay for the cardiovascular testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that this testing was not ordered by the 
enrollee's treating physician. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has alleged that a fraudulent physician order has been 
submitted. The Plan has not included evidence to show that this testing was not ordered by the enrollee's 
treating physician. Of note, there is no evidence that the Plan requested records to indicate if the physician 
order was valid. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the 
file includes a written order and the Plan's denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for the cardiovascular testing (81479) provided on March 1, 
2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extracranial arteries (93880) provided on 
January 4, 2022. 
 
You asked the Plan to pay for the duplex scan of extracranial arteries. You say that you would like this claim to 
be reconsidered for coverage. The Plan denied your request. The Plan says this service does not meet the 
coverage requirements in the applicable Local Coverage Determination (LCD) or National Coverage 
Determination (NCD). 
 
The Plan follows Medicare rules. Medicare rules say that cerebrovascular arterial studies may be considered 
medically necessary if one or more of the signs and symptoms listed in the Medicare rules section above are 
present. 
 
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 of extracranial arteries. Our 
reviewer says that the duplex scan of extracranial arteries was not medically reasonable and necessary. Our 
physician reviewer found The Centers for Medicare & Medicaid Services (CMS) requires a medical symptom 
for duplex ultrasound of the carotid arteries and does not cover screening for carotid ultrasound. The enrollee's 
history of a pre-operative coronary artery bypass graft (CABG) does not constitute a valid symptom for 
consideration. Our reviewer also found that while the exam was done, the indications are not recognized by 
CMS for reimbursement. 
 
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 of extracranial arteries have not been met. Therefore, we 
decided that the Plan does not have to pay for the duplex scan of extracranial arteries (93880) provided on 
January 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cyanocobalamin (Vitamin B-12) (82607) and  pyridoxal 
phosphate (Vitamin B-6) (84207) provided on July 27, 2021. 
 
You asked the Plan to pay for the vitamin B-12 and vitamin B-6 testing. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed 
diagnosis codes do not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT codes 82607 and 84207 are not supported in the record. Specifically, per the governing LCA, 
CPT codes 82607 and 84207 may be considered medically necessary when billed with specific diagnosis 
codes. This claim was not billed with an appropriate diagnosis code to support medical necessity. Based on this 
information, we decided that Medicare rules for coverage of the vitamin B-12 and vitamin B-6 testing have not been met. Therefore, we decided that the Plan does not have to pay for cyanocobalamin (Vitamin B-12) 
(82607) and  pyridoxal phosphate (Vitamin B-6) (84207) provided on July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) and to pay more 
for the eye exam (92004) provided on January 21, 2022. 
 
You asked the Plan to pay for the determination of refractive state or pay more for the eye exam. You say that 
this was not duplicate billing. The Plan denied your request. The Plan says you were correctly charged for the 
office visit. The Plan also says that refractions are not covered by the Plan because this treating provider is not 
a Plan approved vision provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when reimbursement is requested from the Plan's approved vision 
provider directly if the service is rendered by an out-of-network provider. You are also responsible for a $25 
copayment for specialist office visits.  
We looked at the file and the Plan's rules. You were correctly charged a $25 copayment for the medical eye 
exam. You were also correctly denied coverage for the refraction because it would only be covered from a non-
Plan approved vision provider if reimbursement is requested from the Plan's approved vision provider directly. 
Based on this information, we decided that the Plan's rules for coverage of the determination of refractive state 
or pay more for the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for 
the determination of refractive state (92015) and to pay more for the eye exam (92004) provided on January 21, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 1, 2022 by an out-of-
network (OON) provider. 
 
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 the services were rendered by an out-of-network provider without prior 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 office visit provided on February 1, 2022 by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on November 8, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that FANCC genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is FANCC genetic testing. Therefore, we decided 
that the Plan does not have to pay for the FANCC genetic testing rendered on November 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a removal of a foreign body from the ear canal (69200) 
provided on January 18, 2022. 
 
You asked the Plan to pay for a removal of a foreign body from the ear canal. You say that the services at issue 
were a medical necessity for you and are covered under your policy. The Plan denied your request. The Plan 
says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and anatomic modifiers when appropriate. 
 
In this case, the CPT Code Manual definition of code 69200 is "Removal foreign body from external auditory 
canal; without general anesthesia." 
 
We find that CPT code 69200 was not billed with the appropriate anatomic modifier. Based on this 
information, we decided that Medicare rules for coverage of a removal of a foreign body from the ear canal 
have not been met.  
  
Therefore, we decided that the Plan does not have to pay for a removal of a foreign body from the ear canal 
(69200) provided on January 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood smear interpretation (85060) provided on December 
6, 2021. 
 
You asked the Plan to pay for a blood smear interpretation. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that radiology and other diagnostic services furnished 
to hospital outpatients are paid under the OPPS to the hospital. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a blood smear interpretation have not been met. Specifically, the record indicates that this service 
was rendered in an outpatient facility. CPT code 85060 has a professional/technical component indicator of 8. 
This means that no payment is recognized for the code when furnished to hospital outpatients or non-hospital 
patients. Therefore, we decided that the Plan does not have to pay for a blood smear interpretation (85060) 
provided on December 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing rendered on October 21, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that FANCC genetic testing is non-covered. 
 
We looked at the file and Medicare rules. The testing at issue is FANCC genetic testing. Therefore, we decided 
that the Plan does not have to pay for the FANCC genetic testing rendered on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for procedures on the knee and popliteal area 
(01380) provided July 22, 2021.  
You asked the Plan to pay for the anesthesia services. You say that this claim was incorrectly denied. Please 
review the attached records showing general anesthesia was administered and reprocess for payment. The Plan 
denied your request. The Plan says the records do not meet NCD/LCD criteria. 
 
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 anesthesia services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee ho underwent a procedure on the knee and popliteal area under 
anesthesia (CPT code 01380-QZ-P3-X4) on 7/22/2021.  The anesthesiology records/photocopies submitted are 
illegible due to poor copy quality. The procedure and anesthesia care cannot be verified due to the poor 
quality/illegible anesthesia records. 
 
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 anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia for procedures on the knee and popliteal area (01380) provided July 22, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services for a total knee arthroplasty (TKA) procedure 
(01402) provided on May 19, 2021. 
 
You asked the Plan to pay for anesthesia for a TKA. You say that the original charge was reversed and a refund 
was issued. The Plan denied your request. The Plan says that rules for payment have not been met because the 
claim at issue is a duplicate of a prior claim that has been processed and paid. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say that an exact duplicate for physician and other supplier claims is a claim that 
exactly matches another claim or claim line with respect to, among other items, provider number, date of 
service, procedure code, place of services, and billed amount. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has provided documentation of a prior claim for the same 
provider number, date of service, and procedure code but a different billed amount. Therefore, the case record 
does not support that the claim at issue is a duplicate of a prior claim. It is the Plan's responsibility to 
substantiate its denial. In this case, the denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for anesthesia services for a total knee arthroplasty (TKA) 
procedure (01402) provided on May 19, 2021.  
 
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.