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

 
We decided that the Plan does not have to pay for pulmonary ventilation and perfusion imaging (78582) 
provided on October 10, 2022. 
 
You asked the Plan to pay for pulmonary ventilation and perfusion imaging (78582). You say that the 
procedure was rendered in the appropriate place of service and the claim should be reconsidered for payment. 
The Plan denied your request. The Plan says an inappropriate place of service was billed. 
 
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 78582 is pulmonary ventilation (eg, aerosol or gas) and 
perfusion imaging.  We find that CPT code 78582 is not supported in the medical record. Specifically, the enrollee was an inpatient 
on this date of service, but the outpatient POS was billed. Based on this information, we decided that Medicare 
rules for coverage of pulmonary ventilation and perfusion imaging (78582) have not been met. Therefore, we 
decided that the Plan does not have to pay for pulmonary ventilation and perfusion imaging (78582) provided 
on October 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Solid Tumor & Heme Comprehensive 
Genomic Profiling (CGP) testing provided on September 15, 2022. 
 
You asked the Plan to pay for the Tempus xT Solid Tumor & Heme CGP testing. You say that the Tempus xT 
Solid Tumor & Heme Comprehensive Genomic Profiling (CGP) testing provided on September 15, 2022, was 
medically necessary. The Plan denied your request. The Plan says the Tempus xT Solid Tumor & Heme 
Comprehensive Genomic Profiling (CGP) testing provided on September 15, 2022, was not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the Tempus xT Solid Tumor & Heme CGP 
testing. Our reviewer says that the Tempus xT Solid Tumor & Heme Comprehensive Genomic Profiling (CGP) 
testing provided on September 15, 2022, was not medically necessary. Our physician reviewer found without 
staging information the need for molecular testing cannot be assessed. The practitioner can resubmit with 
staging to assess the need for the molecular testing. 
 
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 Tempus xT Solid Tumor & Heme CGP testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Tempus xT Solid Tumor & Heme 
Comprehensive Genomic Profiling (CGP) testing provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to issue additional reimbursement for the acupuncture treatments (97813) 
provided from December 8, 2021, through August 27, 2022. 
 
You asked the Plan to issue additional reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that payment was 
issued correctly in accordance with the Medicare allowed amounts for these services. 
 
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 Evidence of Coverage (EOC) contract does not state that if an 
enrollee utilizes a licensed acupuncturist, rather than a provider allowed by Original Medicare, the coverage 
will be limited to the Medicare allowable amount. The Plan has not substantiated their denial; therefore, we 
must find in your favor. The Plan must pay the difference between the billed charges that were paid and the $25 
copayment for each visit. Therefore, we decided that the Plan has to issue additional reimbursement for the 
acupuncture treatments (97813) provided from December 8, 2021, through August 27, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that the records support the treatment decision. The 
Plan denied your request. The Plan says an incorrect place of service was billed. 
 
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 claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 provided on July 14, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service November 5, 
2022 to December 2, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service November 5, 2022 to December 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72192 billed for date of service December 
11, 2022. 
 
You asked the Plan to pay for procedure code 72192. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 72192 is bundled into payment for code 
74176. 
 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 72192 
is a column II code to column I code 74176. 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 72192 billed for date of service December 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 20, 2021, billed 
with codes 81225, & 81226. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an genetic testing 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 December 20, 2021, billed with codes 81225, & 81226.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology (81479) provided February 
18, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the doctor ordered a blood biopsy and the 
Guardant360 test in order to assist determining the optimal treatment options for the enrollee. The Plan denied 
your request. The Plan says this genetic test is considered investigational and experimental. 
 
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 was no documentation included with the appeal explaining 
how each gene is necessary for therapeutic decision making for the enrollees treatment course. Based on this 
information, we decided that Medicare rules for coverage of the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for the unlisted molecular pathology (81479) provided 
February 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex procedure (22867). 
 
You asked the Plan to pre-approve a Coflex procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
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 a Coflex procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that current evidence-based medical guidelines and peer-reviewed literature do not fully 
support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a 
lack of large-volume, long-term, peer-reviewed outcome studies to support the use of this device for the 
enrollees medical condition. 
 
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 Coflex procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Coflex procedure (22867).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 51798-26 provided on October 18, 2022. 
 
You asked the Plan to pay for procedure code 51798-26. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says code 51798 is not payable with modifier 
26. 
 
The Plan must follow Medicare rules. The rules say a PC/TC indicator of 3 means that the code is a stand-alone 
code that describes the technical component (i.e., staff and equipment costs) of selected diagnostic tests for 
which there is an associated code that describes the professional component of the diagnostic tests only. 
 
We looked at the file and Medicare rules. Procedure code 51798-26 has a PC/TC Modifier Status of 3, which 
specifies a Technical Component only code. Please note that the Plan has confirmed that you are not 
responsible for any charges of this code. Therefore, we decided that the Plan does not have to pay for procedure 
code 51798-26 provided on October 18, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says step-therapy rules for coverage of the requested drug 
have not been met. 
 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 Feraheme. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
Plan requires a trial of drugs Infed and Venofer before they will approve the requested drug, Feraheme. There 
is no indication in the case record that the enrollee has tried and failed the required drugs. Based on the medical 
records provided and the Medicare-approved major drug compendia, there is no indication that the Plan's 
required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve treatment with Feraheme (Q0138).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
13, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that separate procedures were performed, and 
the claim should be reprocessed. 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 September 13, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are multiple plausible pathologic sources of significant pain generation. 
The non-radiating midline back pain, the noted pain-aggravating factors (bending forward, exercise, climbing 
stairs, walking, work, and prolonged sitting), pain-relieving factors (lying down, ice, heat, sitting, and 
medications), the diminished spinal motion, and intact neurologic exam were/are all non-specific to any 
pathologic entities. Overall, documentation was/is lacking regarding reasonably detailed and/or evidenced 
findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the 
enrollees chronic persistent pain. The available documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services rendered on October 21, 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with mismatched diagnosis 
codes. 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 surgical pathology services rendered on 
October 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided July 22, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with this decision and request 
prompt review of and authorization of coverage for the Cxbladder Detect test for this enrollee. The Plan denied 
your request. The Plan says this service is not covered by Medicare or the Plan. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cxbladder detect test (0012M) provided July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator purchased on July 14, 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. The rules say that reimbursement for oxygen equipment is limited to 36 
monthly rental payments. 
 
We looked at the file and Medicare rules. The file shows that the oxygen equipment was not rented but 
purchased outright. 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 oxygen concentrator 
purchased on July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect (0012M) provided June 7, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you disagree with this decision and 
appreciate prompt review of this information and authorization of coverage for the Cxbladder Detect test for 
this enrollee. 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 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. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Cxbladder detect (0012M) provided June 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93005 billed for September 17, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
We looked at the file and Medicare rules. Billed procedure code 93005 has an OPPS status indicator of Q1(s) 
and was billed with code 99285, which has an OPPS status indicator of V. Code 93005 is not separately 
payable when billed with a code with an OPPS status indicator of V. Therefore, we decided that the Plan does 
not have to pay for procedure code 93005 billed for September 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory polymerase chain reaction (PCR) panel 
provided on October 19, 2022. 
 
You asked the Plan to pay for the respiratory PCR panel. You say that this testing was medically necessary. 
The Plan denied your request. The Plan says this testing is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed 
in the Part B outpatient setting are considered not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. In this case the records show that this panel tested for more than 5 
respiratory pathogens. Based on this information, we decided that Medicare rules for coverage of the 
respiratory PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
respiratory polymerase chain reaction (PCR) panel provided on October 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel (87500, 
87801, 87640, 87653, 87798, 87481, 87150) provided on November 17, 2022. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing is not experimental or 
investigational. The Plan denied your request. The Plan says this testing should be billed with a single panel 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a 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 urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel (87500, 87801, 87640, 87653, 87798, 87481, 87150) provided on November 17, 2022.