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

 
We decided that the Plan does not have to pre-approve the cervical fusion, anterior (CPT code(s): 22845, 22552 
x2, 22551). 
 
You asked the Plan to pre-approve the surgery. You say that the services are medically necessary due to 
symptoms causing a new neck injury. The Plan denied your request. The Plan says the services are not 
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 the surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the imaging studies and physical exam do not correlate. There is no severe neural compression 
or instability. 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 surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the cervical fusion, anterior (CPT code(s): 22845, 22552 x2, 22551).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve at issue is a skilled nursing facility (SNF) admission and 
services. 
 
You asked the Plan to pre-approve SNF care. You say that you are home alone all day and can't move around. 
The Plan denied your request. The Plan says based on Medicare guidelines, the requested SNF services do not 
meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
SNF care is not medically reasonable and necessary. Our physician reviewer found that you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an 
inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve at issue is a skilled nursing facility (SNF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 27, 2022. 
 
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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 88342 is 4. The MAI value for this code is 2. You billed 6 units of this 
code, exceeding the MUE. 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 laboratory services 
rendered on January 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291, 99292) provided on March 22, 
2022. 
 
You asked the Plan to pay for critical care. You say that the diagnosis codes billed on this claim are valid and 
appropriate. The Plan denied your request. The Plan says it is inappropriate to bill diagnosis code J96.01 and 
R06.02 together. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that some diagnoses are excluded from use with certain other diagnoses. These exclusions are 
indicated with Excludes notes. 
 The claim at issue was billed with diagnosis code R06.02 (shortness of breath) and J96.01 (acute respiratory 
failure with hypoxia). However, R06 diagnosis codes have an Excludes1 note with respiratory failure diagnosis 
codes (J96.-). This means that R06 codes generally cannot be used with J96 codes. Based on this information, 
we decided that Medicare billing rules have not been met. Therefore, we decided that the Plan does not have to 
pay for critical care services (99291, 99292) provided on March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 29, 2021 billed with 
codes 81206, 81235, 81292, 81301, and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not billed correctly. 
 
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 29, 2021 billed with codes 81206, 81235, 81292, 81301, and 81321.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Collection of venous blood by venipuncture (36415) 
comprehensive metabolic panel (80053) thyroxine (84436) provided on April 14, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 Collection of venous blood by venipuncture 
(36415) comprehensive metabolic panel (80053) thyroxine (84436) provided on April 14, 2022 by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for 621 units of code Q9967 (low osmolar contrast material) billed for date 
of service December 16, 2021. 
 
You asked the Plan to pay for 621 units of code Q9967. You say that these services were appropriate and based 
on accepted clinical guidelines. The Plan denied your request. The Plan says that you billed 621 units of low-
osmolar contrast material (code Q9967) for date of service December 16, 2021. The MUE value for this code is 
300. There is no evidence of medical necessity as to why more than 300 units of this code should have been 
billed. 
 
The Plan follows Medicare rules. Medicare rules say that generally, if a code has a MAI of '3', it means that the 
MUE for that code is generally the limit of units that will be medically necessary.  However, additional units of 
the code may be paid if medically necessary. Code Q9967 has a MAI of 3 and an MUE of 300. 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 621 units of code Q9967. Our reviewer says that 621 units of 
Q9967 are medically necessary in this case. Our physician reviewer found the computed tomography scans of 
the chest, abdomen and pelvis done on this date included IV injection of 121ml and the oral intake of 
500ml. The total contrast material was thus 621ml. The use of this contrast as an oral agent is recognized as a 
way to opacify the bowel without adding toxicity. We looked at this physician's review, the file, and Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of 621 units of code Q9967 have 
been met. Therefore, we decided that the Plan has to pay for 621 units of code Q9967 (low osmolar contrast 
material) billed for date of service December 16, 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 ultrasound (76604) provided on March 21, 2022. 
 
You asked the Plan to pay for the ultrasound. You say that this service was billed appropriately. The Plan 
denied your request. The Plan says this claim was submitted with an incorrect Place of Service (POS) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate POS code. The rules say that when services are rendered to 
a patient who is registered inpatient of a hospital, the correct POS code, regardless of where the face-to-face 
service occurs, is that of the appropriate inpatient POS code. 
 
We find that POS code 22 (on campus- outpatient hospital) is not supported in the record. Specifically, the file 
shows that the enrollee was registered inpatient status from March 12, 2022, to March 23, 2022. This means 
that the ultrasound provided on March 21, 2022, should be billed with an inpatient POS code.  Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. 
Therefore, we decided that the Plan does not have to pay for the ultrasound (76604) provided on March 21, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT code 63650). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because your records show you have not had 
therapy, surgical treatment or that you are not a surgical candidate. The Plan states you have not had maximal 
medical management and there is no documentation of recent physical therapy. The Plan states there is not 
adequate documentation of any form of neurosurgical evaluation that indicates that you are not a surgical 
candidate. The Plan states you have two surgeries pending authorization at this time per your medical records 
as alternatives to this procedure. 
 
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 services. Our physician reviewer 
found there was no documentation provided of prior lumbar spine surgery. Nor was documentation provided 
that you had a surgical evaluation and was determined not to be a surgical candidate. This would ultimately fail 
to meet the requirements of the NCD. 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 services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (CPT code 63650).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the ultrasound scan of the abdomen 
provided on March 31, 2022. 
 
You asked the Plan to waive the cost share for the ultrasound. You say that you are the only one in the family 
that works, and your husband is sick and stays home. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible. This is the amount you have to pay out-of-pocket 
before the Plan will pay their share for your covered medical services. Until you have paid the deductible 
amount, you must pay the full cost of your covered services. At the time this claim was processed, $0 of the 
$750 deductible had been met. The allowed amount of this claim is $147, resulting in a deductible amount of 
$147. 
 
You have been asked to pay the allowed amount of $147 for the ultrasound. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $750 deductible which applies to Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met 
at the time the ultrasound was received on March 31, 2022. Therefore, we decided that the Plan does not have 
to waive the cost share for the ultrasound scan of the abdomen provided on March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this device is medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says this device 
is considered experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted molecular pathology service (81479-GZ) billed 
for date of service July 6, 2020. 
 
You asked the Plan to pay for the unlisted molecular pathology service. You say that this service was necessary 
and appropriate. The Plan denied your request. The Plan says this service does not meet Medicare criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules state that items submitted with a 
GZ modifier shall be denied automatically and will not be subject to complex medical review. We find that CPT code 81479-GZ is not supported in the record. Specifically, this service was billed with a GZ 
modifier, which means that this service does not meet Medicare criteria for coverage. Based on this 
information, we decided that Medicare rules for coverage of the unlisted molecular pathology service have not 
been met. Therefore, we decided that the Plan does not have to pay for an unlisted molecular pathology service 
(81479-GZ) billed for date of service July 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you would like more trips to be 
approved for medical reasons. The Plan denied your request. The Plan says you have exhausted all of the 
available trips. The Plan also says extra one-way trips cannot be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 10 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on February 16, 2022. 
 
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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. 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 critical care 
services rendered on February 16, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the brain for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a study similar to the one requested has recently been performed, and no more 
imaging is needed at this time. 
 
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 pre-approve the MRI. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that as this lesion in question has an enhancing mural nodule and has increased slightly in all dimensions 
since January, and due to neurosurgical consideration of surgery a repeat MRI is reasonable. It is noted that 
cystic hemangioblastoma, the presumptive diagnosis, is a rare tumor especially in a 72 year old patient. The 
possibility of a malignant process has to be included in the differential and due to the increase in size between 
the 2 most recent exams a followup scan at the discretion of the neurosurgeon is reasonable and should be 
approved. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the brain for the enrollee.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory (lab) services provided on March 10, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the provider is not 
a network provider, and these services are not urgent or emergent, nor were they approved in advance. 
 
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 laboratory (lab) services provided on March 10, 
2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided from 
October 30, 2021, through November 3, 2021. 
 
You asked the Plan to pay for the pneumatic compression device provided. You say that this was medically 
reasonable and necessary for the enrollees condition. The Plan denied your request. The Plan says this device 
is not covered by Medicare or the Plan. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided from October 30, 2021, through November 3, 
2021.