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

 
We decided that the Plan does not have to pre-approve magnetic resonance guided high intensity focused 
ultrasound (MRgFUS), stereotactic ablation. 
 You asked the Plan to pre-approve magnetic resonance guided high intensity focused ultrasound (MRgFUS), 
stereotactic ablation. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan 
says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that MRgFUS is covered when the enrollee is not a 
surgical candidate for deep-brain stimulation (DBS). 
 
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 magnetic resonance guided high 
intensity focused ultrasound (MRgFUS), stereotactic ablation. Our reviewer says that the documentation does 
not support that the requested service is medically reasonable or necessary. Our physician reviewer found the 
enrollee has essential tremor using primidone, propranolol, and zonegran with limited benefit. The enrollee 
appears to be a candidate for deep brain stimulation (DBS) treatment. DBS was even planned for this enrollee 
but delayed due to chest congestion/asthma. The LCD criteria require the enrollee to not be a candidate for 
DBS, and this enrollee is a candidate and has not yet tried this therapy as required. Therefore, the enrollee does 
not meet criteria for the requested 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 magnetic resonance guided high intensity focused ultrasound (MRgFUS), 
stereotactic ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
magnetic resonance guided high intensity focused ultrasound (MRgFUS), stereotactic ablation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 13, 2022 billed with 
codes 0031U, 0032U, 0033U, 81225, 81226, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81335, & 
81355 
. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 
January 13, 2022 billed with codes 0031U, 0032U, 0033U, 81225, 81226, 81227, 81230, 81231, 81232, 81291, 
81306, 81328, 81335, & 81355 
.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (81455) 
provided February 1, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that F1Heme was ordered by treating physician 
because the results were needed to help determine the course of treatment for this enrollee. The Plan denied 
your request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
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 81455 is targeted genomic sequence analysis 51 or 
greater genes. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the claim was billed with a 
date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on 
October 29, 2021 and not the billed date of service February 1, 2022. 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 the targeted genomic sequence analysis panel (81455) provided February 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan of extracranial arteries; complete bilateral 
study (93880) provided December 22, 2021. 
 
You asked the Plan to pay for the ultrasound of both sides of head and neck blood flow. You say that only 
services that are needed to render an accurate diagnosis are ordered. The Plan denied your request. The Plan 
says there was insufficient information submitted to determine medical necessity. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case office/visit notes were not supplied for review. None of 
the reported diagnoses are listed in the LCD as covered. Without these notes we cannot determine if conditions 
for coverage met. Based on this information, we decided that there is insufficient information in the record to 
determine if Medicare rules for coverage of the duplex scan of extracranial arteries; complete bilateral study 
(93880) provided December 22, 2021.  Therefore, we decided that the Plan does not have to pay for the duplex 
scan of extracranial arteries; complete bilateral study (93880) provided December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a general health panel (80050) provided on August 25, 2020. 
 
You asked the Plan to pay for a general health panel. You say that you disagree with the denial of this claim. 
The Plan denied your request. The Plan says code 80050 is excluded by Medicare and therefore not payable by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for a general health panel 
(80050) provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided on October 27, 2021. 
 
You asked the Plan to pay for critical care services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this is not documented. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, no documentation of critical 
care services being performed on October 27, 2021, has been submitted. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan 
does not have to pay for critical care services (99291) provided on October 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial as 
clinicals were attached. The Plan denied your request. The Plan says the inpatient stay was not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollees 
condition can be managed safely only in the inpatient hospital setting.  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 acute inpatient hospital care. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found in the emergency 
department (ED), the enrollee was noted to have U/A with pyuria, but without fever or leukocytosis. All other 
labs and imaging were normal/nonacute. She was given antibiotics and pain meds in the ED. She was then 
admitted continuing pain meds and antibiotics and had an inpatient stay from 7/28/22 - 8/11/22. However, 
based on the presentation and ED workup and treatment, the enrollee did not warrant inpatient hospitalization 
as she could have been safely treated at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74177 billed for date of service February 10, 
2022. 
 You asked the Plan to pay for procedure code 74177. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 74177 is bundled into 
payment for code 74174. 
 
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 74177 
is a column II code to column I code 74174. 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 74177 billed for date of service February 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code  billed for date of service March 7, 2022. 
 
You asked the Plan to pay for procedure code . You say that you disagree with the denial. The Plan denied your 
request. The Plan says the number of units billed exceeds the maximum allowed.  
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 95887 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 
procedure code  have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code  billed for date of service March 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography (95810). 
 
You asked the Plan to pre-approve a polysomnography. The Plan denied your request. The Plan says this 
request is not medically necessary because the enrollee has good response with the continuous positive airway 
pressure machine, and no settings will need to change with a new CPAP machine. 
 The Plan follows Medicare rules. Medicare rules say that follow-up polysomnography or sleep studies are not 
routinely indicated for patients treated with CPAP whose symptoms continue to be resolved with CPAP 
treatment. 
 
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 polysomnography. Our reviewer says 
that the enrollee does not meet the criteria for coverage for a polysomnography (95810) Our physician reviewer 
found the documentation indicates that the enrollee has good control of their established sleep apnea diagnosis 
with the use of CPAP. The enrollee's CPAP machine broke, and they are in need of a new one. Our reviewer 
also found that the enrollee had no changes in their condition which would warrant a new sleep study prior to 
obtaining a new CPAP machine. 
 
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 polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a polysomnography (95810).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0012M) provided on March 29, 2022. 
 
You asked the Plan to pay for CxBladder testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says This service is not covered by Medicare and is considered unproven in 
clinical literature and by the National Comprehensive Cancer Network (NCCN). 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not 
been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0012M) provided on 
March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 6, 2022 billed with 
codes 81317, 81292, 81298, and 81295. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 6, 2022 billed with codes 81317, 81292, 81298, and 81295.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10021 billed for date of service November 3, 
2021.  
You asked the Plan to pay for procedure code 10021. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
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 10021 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 
procedure code 10021 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 10021 billed for date of service November 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that you understand the enrollee would qualify for Evenity 
following failure of an antiresorptive, but it would be an unfortunate and costly mistake to disregard the ideal 
sequence of use for this essential medication. The Plan denied your request. The Plan says the Evenity 
prescription is denied as not meeting step therapy criteria. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that Evenity 
is not reasonable and necessary for the enrollee. Our physician reviewer found there is no indication that the 
enrollee has tried and failed the required drug(s). There is no indication that both of the Plan's required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. Our reviewer also found that 
the Medicare-approved major drug compendia contain some comparative data showing superiority of the 
Evenity over Alendronate, but no data showing superiority of Evenity over Prolia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 
You asked the Plan to pre-approve the ILR procedure. You say that it is felt that this is necessary to allow the 
doctor to evaluate the cause of the enrollee's symptoms. The Plan denied your request. The Plan says this is not 
shown to be 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 the ILR procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while the enrollee has a history of atrial fibrillation, there is no documentation 
provided to suggest a history of unexplained syncope, or any other apparent indication for an ILR. In summary, 
there is insufficient documentation to support the medical necessity for insertion of an ILR in this enrollee's 
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 the ILR procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve placement of an implanted loop recorder (ILR).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232) billed for date of service 
April 3, 2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that these services were necessary and were 
reported correctly. The Plan denied your request. The Plan says these services may only be paid once per day 
by providers of the same specialty in the same medical group. Subsequent hospital care has already been paid 
to one of these providers. 
 
The Plan must follow Medicare rules. Medicare rules say that initial hospital care is a per diem service which 
may be reported only once per day by the same physician or physicians of the same specialty from the same 
group practice.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of initial hospital care have been met. Specifically, the enrollee was seen by two providers with the same specialties and taxonomy codes. Therefore, we decided that the Plan does not have to pay for subsequent 
hospital care (99232) billed for date of service April 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 25, 2022 billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, & 91294. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service is medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 25, 2022 billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, & 91294.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine without contrast (72148). 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that you have had multiple serious 
falls where all of your ribs on your right side have had fractures. The MRI was requested to figure out a course 
of treatment that makes you feel best. The Plan denied your request. The Plan says you do not meet the 
required criteria. 
 
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 lumbar spine. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the available 
documentation in the case file does not support that an MRI of the lumbar spine without contrast is medically 
reasonable and necessary for you at this time. Additional imaging is not needed 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 an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine without contrast 
(72148).