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

 
We decided that the Plan has to pay for testing services (U0005, U0004) provided on July 19, 2021. 
 
You asked the Plan to pay for testing services. You say that this claim was originally filed timely. The Plan 
denied your request. The Plan says that although there is evidence that the claim was originally submitted on 
May 26, 2022, the corrected claim for these services was not submitted until July 31, 2022, which is past the 
timely filing limit. 
 
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 testing services was filed on May 26, 2022. This means that less than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
has to pay for testing services (U0005, U0004) provided on July 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6241) for tooth #20 and retainer crowns 
(D6751) for tooth #'s 19 and 21. 
 
You asked the Plan to pre-approve a pontic and retainer crowns. You say that you would like to appeal these 
services because you need the procedure urgently. The Plan denied your request. The Plan says you do not 
meet the criteria for coverage for a bridge.  
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a pontic and 
retainer crowns when the services are medically necessary and reasonable.  
 
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 pontic and retainer crowns. Our 
reviewer says that the documentation provided does not meet the criteria for coverage for a fixed bridge 
replacing tooth #20. Our physician reviewer found the Plan's criteria says a fixed bridge is considered for 
coverage to replace a single maxillary anterior tooth or two adjacent mandibular anterior teeth if no additional 
posterior teeth are missing. Our reviewer also found that in this case, the tooth to be replaced is a posterior 
tooth and additional posterior teeth are missing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a pontic and retainer crowns have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a pontic (D6241) for tooth #20 and retainer crowns (D6751) for tooth #'s 19 
and 21.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (0037U) provided on July 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service should be covered. The Plan denied 
your request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services (0037U) provided 
on July 25, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided on May 18, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that you billed with 
an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. The records show the specimen was collected and received by the lab 
at the same time. There is no evidence that the specimen was collected at an office visit. POS code 81 is 
appropriate. Based on this information, we decided that Medicare rules for coverage of the lab services have 
been met. Therefore, we decided that the Plan has to pay for lab services provided on May 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry visits provided on June 13, 2022. 
 
You asked the Plan to waive the copayment for podiatry visits. You say that this should be covered. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Podiatry visits. 
 
You have been asked to pay a $35 copayment for podiatry visits. This item/service falls within the Podiatry 
visits benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for podiatry visits provided on June 
13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ATN1 (atrophin 1) gene analysis (81177). 
 
You asked the Plan to pre-approve ATN1 gene analysis. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not medically necessary as the results of this test are 
unlikely to impact therapeutic decision-making, directly impact treatment, outcome and/or clinical management 
in the enrollee's care. 
 
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 ATN1 gene analysis. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee reported weight loss due to difficulty swallowing and ataxia. The 
enrollee was reported to have been tested for other possible diagnoses which came back negative, and that increased dosage of tetrabenazine has been helping with his difficulty with swallowing. A request for pre-
approval of ATN1 (atrophin 1) gene analysis (81177) was made in order to identify if the enrollee has a repeat 
expansion of this gene which is common in dentatorubral pallidoluysian atrophy (DRPLA). However, although 
learning if this disease is causing the enrollees symptoms would be interesting, it would not lead to any proven 
treatment method as there is insufficient evidence to support treating this condition (DRPLA). Therefore, 
unless treatment leads to improved outcome for this enrollee it will be considered 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 ATN1 gene analysis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ATN1 (atrophin 1) gene analysis (81177).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper 
extremity (73218). 
 
You asked the Plan to pre-approve an MRI of the upper extremity. You say that you need an MRI because you 
are in a lot of pain. The Plan denied your request. The Plan says the current evidence does not meet medical 
necessity criteria for the requested imaging. The Plan also says that according to the provider, you have been 
referred to an orthopedist for appropriate evaluation. 
 
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 upper extremity. Our 
physician reviewer found your doctor found no abnormality on physical exam and has stated no reason for MRI 
was apparent. You have had limited physical therapy (PT) evaluation and apparently do home exercises, but no 
completion of a PT program is in the records and no post PT evaluation is in the records. Our reviewer found 
that your doctor has referred you to an orthopedist for imaging/treatment and no such evaluation has occurred. 
Our physician reviewer also found that absent such evaluation, the medical necessity of MRI of the left upper 
extremity has not been established. 
 
 
  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 upper extremity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper extremity (73218).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility admission and 
services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not meet the requirements for IRF and may safely receive 
services in alternate settings if requested such as a skilled nursing facility, outpatient setting or home health 
care. 
 
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 Document does not support medical necessity for admission to an IRF. The enrollee has no current medical complexity or rehab nursing needs other than routine nursing care. While the enrollee 
may benefit from physical therapy (PT) and occupational therapy (OT), the enrollee's rehabilitation needs can 
be safely met in an alternate and low intensity setting such as in a skilled nursing facility (SNF). 
 
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 acute inpatient rehabilitation facility admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia and biopsy rendered on May 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 billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with POS code 21 for 
inpatient but the documentation shows the services were rendered in the outpatient setting. Therefore, we 
decided that the Plan does not have to pay for the anesthesia and biopsy rendered on May 16, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided on September 24, 2019, to 
September 27, 2019, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
services and conditions were reported correctly and are supported as billed. The Plan denied your request. The 
Plan says that the DRG submitted on this claim is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with acute respiratory failure, unspecified (J96.00). 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that this diagnosis is supported in the medical record. Our physician 
reviewer found that the enrollee was admitted and treated in the hospital. She presented obtunded and intubated 
due to drug overdose in a suicide attempt. She was treated with fluids, N-acetyl cysteine (NAC), and 
mechanical ventilation support. Based on the fact that the patient was obtunded, required vent support, for an 
abnormal arterial blood gas (ABG) and listed diagnosed as determined by the treating physician as found in the 
documentation. Therefore, the documentation supports the diagnosis of acute respiratory failure for this 
admission.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided on September 24, 2019, to September 27, 2019, at the Diagnosis Related Group 
(DRG) originally billed.  
 
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 shoulder surgery (23430, 23472). 
 
You asked the Plan to pre-approve shoulder surgery. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request 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 shoulder surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that a formal updated left-shoulder report of a magnetic resonance imaging (MRI) scan was not 
provided for review to corroborate recurrent rotator cuff tear that is irreparable. Additionally, detailed 
documentation is not evident in the case record regarding a trial and failure of recent, reasonable, and 
comprehensive less invasive conservative-care measures. There are limited large-scale, long-term references 
showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of shoulder surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve shoulder surgery (23430, 23472).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service March 12, 
2021. 
 
You asked the Plan to pay for procedure code 99232. You say that this claim was filed correctly. The Plan 
denied your request. The Plan says payment for code 99232 is bundled into payment for code 99223. 
 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 99232 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99232 billed for date of service March 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT); 
multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection 
(78452). 
 
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the enrollee recently had a 
nuclear stress test order due to abnormal pre-op. It was needed due to clearance for surgery. This testing is 
medically necessary. The Plan denied your request. The Plan says records do not show that your EKG was 
uninterpretable for poor blood supply or that you had a new irregular heartbeat or that you had recent equivocal 
or borderline testing where ischemia remains a concern. The request 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 myocardial perfusion imaging. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the cardiac PET scan of 8/8/22 was negative and there was no description 
of any suboptimal component or equivocal finding which required any further imaging evaluation. In particular 
during the Lexiscan or stress portion of this exam, the ECG showed no ischemic changes and was considered 
normal by the interpreting physician. No change in symptoms was noted and the cardiac echo of 8/23/22 
showed no abnormality with normal wall motion. The nuclear medicine stress test of 12/3/22 included SPECT 
imaging but the exam was done for pre op clearance and justification for the SPECT imaging was not 
explained in light of the negative cardiac PET scan of 8/8/22 which also had included stress imaging. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that 
the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT); multiple studies, 
at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service July 27, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 70544 is bundled into payment for code 70551.  
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 70544 
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70544 billed for date of service July 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neck support (L0180) provided on July 19, 2022. 
 
You asked the Plan to pay for the neck support. You say that this item was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed item. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for a neck support (L0180) provided on July 19, 2022.