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

 
We decided that the Plan does not have to pre-approve cytogenomic (genome-wide) analysis for constitutional 
chromosomal abnormalities; interrogation of genomic regions for copy number and single nucleotide 
polymorphism (SNP) variants, comparative genomic hybridization (CGH) microarray analysis (81229). 
 
You asked the Plan to pre-approve Genome-wide microarray analysis for copy number and single nucleotide 
polymorphism (SNP) variants. You say that this testing is medically necessary. The Plan denied your request. 
The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that this test is subject to coverage determinations 
made through the MolDX Program. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. This 
determination was made and is specific to the test at issue. 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 pre-approve cytogenomic (genome-wide) analysis for constitutional chromosomal 
abnormalities; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) 
variants, comparative genomic hybridization (CGH) microarray analysis (81229).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the most appropriate place 
for the enrollee to continue their care. The Plan denied your request. The Plan says the Medicare guidelines for 
LTACH admission were not met and when the enrollee is ready to leave the hospital their needs can be met in a 
skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be performed at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous at this time. Completion of treatment at the current facility is 
recommended. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the lumbar spine. 
 
You asked the Plan to pre-approve a CT scan of the lumbar spine. The Plan denied your request. The Plan says 
that there is no clinical documentation to support the requested CT of the lumbar spine. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the lumbar spine. Our 
reviewer says that a CT scan of the lumbar spine is reasonable and necessary. Our physician reviewer found it 
appears the enrollee has an implanted device which may contraindicate a repeat magnetic resonance imaging. 
Our reviewer also found that since the enrollee is due for a repeat lumbar radiofrequency ablation in November 
according to the records, the request for a CT of the lumbar spine would be reasonable to look for degenerative 
changes of the lumbar spine and provide a target for radiofrequency ablation. 
 
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 CT scan of the lumbar spine have been met. Therefore, we decided that the 
Plan has to pre-approve a computed tomography (CT) scan of the lumbar spine.  
 
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 pay for outpatient hospital visit services provided to the enrollee on 
June 21, 2022. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not urgent, emergent, or approved in advanced. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
review has determined that the enrollee could have foreseen requiring the services prior to leaving her service 
area. It would have been medically reasonable to delay the services until when enrollee returned to his/her 
service area. 
 
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 pay for outpatient hospital visit services provided to the enrollee on June 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that you are making progress and want to 
continue with therapy. The Plan denied your request. The Plan says the documentation does not clearly support 
the need for continued therapeutic exercise. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 
 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 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the requested therapy is generally accepted as a specific and effective 
therapy for weakness and impaired gait after a spinal cord injury. The most recent documentation indicates that 
you are using ankle foot orthoses for assistance with mobility and ambulating 300 feet with a walker. Our 
reviewer also found that you continue to have functional deficits with mobility, but it is unclear in the 
documentation if you are continuing to make objective improvement in terms of your functional mobility, and 
if the services of a skilled physical therapist are required versus the enrollee continuing to make improvements 
in strength and endurance with a home exercise program. 
 
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 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollees clinical condition meets full inpatient 
acute rehab criteria, and the lower level of care in SNF would keep her away from her home for a longer 
amount of time. The Plan denied your request. The Plan says IRF is not medically necessary. 
 
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 the enrollee does not require the intensity of services provided at an IRF. The 
enrollees care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve various vascular radiology services (75822, 36012, 
37252, 37253, 76937, 99152, 99153, 75825, 36011) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show any clear history of blood clot in either leg. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support the medical necessity of the invasive imaging in question. There 
is documentation that the patient is happy other than painful skin varicosities. On physical examination the 
patient has no swelling other than +1 pedal edema. There is no documentation of whole leg swelling. There is 
no sign of proximal venous obstruction noted on duplex and no noninvasive studies have been performed on 
the pelvis. There is documentation that the patient has bilateral Bakers cysts that do not appear to have been 
addressed. 
 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 various vascular radiology services (75822, 36012, 37252, 37253, 76937, 99152, 99153, 
75825, 36011) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
4, 2021, to May 1, 2021.  
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the RAP was not submitted in the required time frame. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the RAP 
claim for the services were not submitted until July 29, 2021. This means the RAP was not submitted within 
the required time frame. Therefore, we decided that the Plan does not have to pay for the home health services 
provided to the enrollee from April 4, 2021, to May 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing of 22 or more classes (G0483) provided on 
August 13, 2021. 
 
You asked the Plan to pay for drug testing. You say that the clinical regulations of this provider's office require 
complete presumptive urine drug testing for any and all patients who are prescribed opioids. The Plan denied 
your request. The Plan says blanket orders for drug testing are not covered by Medicare, and the medical 
records contained enough information to treat this enrollee without this test. 
 
The Plan must follow Medicare rules. Medicare rules say that blanket orders for drug testing and routine 
standing orders for all patients in a physician's practice are not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Specifically, this test was performed as part of a blanket order or standing order due to the policy of the providers office and not because it was specifically medically necessary 
for this enrollee. Therefore, we decided that the Plan does not have to pay for drug testing of 22 or more classes 
(G0483) provided on August 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to get to your medical appointments. The Plan denied your request. The Plan says you have utilized the 
maximum number of transportation trips allowed per year. 
 
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 20 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 routine transportation trips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96405 provided on June 15, 2022. 
 
You asked the Plan to pay for procedure code 96405. You say that this service was necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this service is included in the global surgery 
period for code 17264. This service was not billed with an appropriate modifier for separate payment. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have not been met. Specifically, payment for CPT code 96405 is included in the 
global surgery package for CPT code 17264, which has a 10-day global surgery period and was provided on 
June 9, 2022. Of note, CPT code 96405 has not been billed with the required modifier to indicate that this 
service would be separately payable. Therefore, we decided that the Plan does not have to pay for procedure 
code 96405 provided on June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for WATS 3D brush biopsy coded as 88361, 88312, 88305 and 
88112 provided November 3, 2021. 
 
You asked the Plan to pay for WATS 3D brush biopsy. You say that WATS 3D is medically necessary as it is 
scientifically proven to be a better method of acquiring esophageal tissue than routine forceps biopsy alone thus 
leading to an increased detection rate which enables physicians to preempt the development of esophageal 
cancer. The Plan denied your request. The Plan says the current medical literature and clinical practice 
guidelines do not generally support the clinical utility of this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of WATS 3D brush biopsy have not been met. Therefore, we decided that the Plan does not have to 
pay for WATS 3D brush biopsy coded as 88361, 88312, 88305 and 88112 provided November 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 15, 2020 billed with 
codes 0031U, 81328, 81355, 81401, 81479, 0032U, 81225, 81226, 81227, 81231, 81230, 81240, 81241, 81291. 
 
You asked the Plan to pay for the genetic testing billed. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your 
request. The Plan says the Hereditary Cardio Panel is not FDA approved nor is it covered by Medicare per Dex 
Diagnostics. 
 
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 15, 2020 billed with codes 0031U, 81328, 81355, 81401, 81479, 0032U, 81225, 81226, 81227, 81231, 
81230, 81240, 81241, 81291.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 25, 
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 June 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bilateral shoulder x-rays (CPT code 73030-26 RT and 
LT) provided on June 27, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Review of the file shows the submitted 
documentation supports one (1) unit of 73030 26 LT which was approved and paid and 1 unit of 73030 26 RT 
which was approved and paid. There is no additional documentation supporting additional services which were 
billed and remain denied. Therefore, we decided that the Plan does not have to pay for the bilateral shoulder x-
rays (CPT code 73030-26 RT and LT) provided on June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360 and 88381 billed for 
date of service March 23, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342, 88360 and 88381. You say that these services 
were necessary and are supported in the medical record. The Plan denied your request. The Plan says these 
services were not billed in accordance with Medicare coding guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that CPT codes 88341, 88342, 88360 and 88381 are physician pathology services which have both 
professional components (PC) and technical components. These services were not billed with modifier 26 to 
indicate that only the professional component payment is requested. This means that payment is requested for 
both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
inpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88341, 88342, 88360 and 88381 have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure codes 88341, 88342, 88360 and 88381 billed for date of service March 23, 2022.