Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array, epidural (63650). 
 
You asked the Plan to pre-approve the spinal cord stimulator (SCS). You say that the enrollee has tried and 
failed oral medications, epidural steroid injections, occupational therapy, and physical therapy. You say that 
their chronic pain affects their ability to perform activities of daily living. You also say that the requested 
treatment is appropriate for the enrollee's condition. The Plan denied your request. The Plan says the requested 
service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that payment may not be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the conditions have been met. 
 
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 spinal cord stimulator (SCS). Our 
reviewer says that the requested spinal cord stimulator (SCS) is not medically necessary. Our physician 
reviewer found the provided documentation does not indicate that the requested service is a late or last resort. 
The reviewer found that the documentation does not support that the enrollee is not a surgical candidate. 
Therefore, the reviewer found that the requested SCS is not medically reasonable or necessary 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 the spinal cord stimulator (SCS) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a percutaneous implantation of neurostimulator electrode array, epidural 
(63650).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on 
September 8, 2022. 
 
You asked the Plan to pay for the initial hospital care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the serviced billed are not separately payable. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs.  Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside 
and on the patient's hospital floor or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, this service was billed on the 
same date of service as code 99291 (critical care). Provider of the service at issue and the critical care service 
were from the same specialty. This means this code is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of the initial hospital care services have not been met. Therefore, we 
decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on 
September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0089U billed for date of service April 25, 
2022. 
 
You asked the Plan to pay for procedure code 0089U. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 0089U is bundled into payment for code 81345. 
 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 0089U 
is a column II code to column I code 81345. 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 0089U billed for date of service April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 
21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging 
with 4 or more additional parameters of sleep, attended by a technologist. 
 
You asked the Plan to pre-approve polysomnography. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that sleep testing is covered when specific criteria are met. 
 
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 polysomnography. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found in this case, there is no 
documentation to support that the enrollee has lung failure, heart failure, seizures, or any other health problems 
that would require an in lab sleep study. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does 
not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional 
parameters of sleep, attended by a technologist.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 
You asked the Plan to pre-approve a sleep study. You say that the requested sleep study is medically necessary 
and needed. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 sleep study. Our reviewer says that a 
sleep study is not considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee has a diagnosis of hypertension (HTN), insulin requiring type 2 diabetes, gastroesophageal reflux 
disease (GERD), chronic rhinosinusitis, and mild obstructive sleep apnea (OSA) with an apnea-hypopnea index 
(AHI) of 7.8. The enrollee was diagnosed with this OSA on September 10, 2012. The enrollee used continuous 
positive airway pressure (CPAP) for a while and now OSA symptoms have returned. The enrollee's OSA 
diagnosis was made before and his OSA symptoms have reappeared; therefore, he does not need a home sleep 
test for diagnosis. The enrollee needs a Split-Night study for diagnosis confirmation and CPAP titration. 
 
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 sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 71045 is bundled into payment for code 71046. 
 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 71045 
is a column II code to column I code 71046. 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 71045 billed for date of service May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BRCA1 and BRCA2 gene analysis (81162) provided on July 
18, 2022. 
 You asked the Plan to pay for BRCA1 and BRCA2 gene analysis. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing is not covered because there is no 
documentation of any signs or symptoms of cancer. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, BRCA1 and BRCA2 gene analysis, is being requested solely for screening 
purposes. A test is considered screening when it is provided in the absence of signs/symptoms of illness or 
injury. In this case, the genetic test at issue is used to determine the presence of inherited cancer-causing 
mutations. However, the records do not show that you have any signs or symptoms suggestive of cancer. The 
documentation supports that this testing is requested due to a family history alone of cancer. This would be 
considered screening testing which is excluded from Medicare coverage. Therefore, we decided that the Plan 
does not have to pay for BRCA1 and BRCA2 gene analysis (81162) provided on July 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the culture, bacterial; quantitative colony count, urine (CPT 
code 87086) provided on June 13, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 laboratory service. Our physician 
reviewer found CPT code 87086 was billed with diagnosis code N31.2 (Flaccid neuropathic bladder, not 
elsewhere classified) which is not listed as an appropriate diagnosis code as per CMS Medicare NCD 190.12. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the culture, bacterial; quantitative colony count, urine (CPT code 87086) provided on 
June 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on August 3, 2022. 
 
You asked the Plan to pay for definitive drug testing. You say that this testing was medically necessary and is a 
covered service. The Plan denied your request. The Plan says the submitted documentation does not include the 
results of a presumptive drug screening. Without evidence of this presumptive testing, the criteria for medical 
necessity of definitive urine drug testing are not met in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is indicated under certain 
conditions.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of definitive drug testing have not been met. Specifically, the documentation provided does not show 
that the enrollee had a screening where there were presumptively positive results or there were results which were negative but inconsistent with the enrollee's medical history. There is no documentation to show that there 
was no presumptive test available but the other coverage criteria of the policy were met. Based on the 
documentation provided, the criteria for medical necessity are not met in this case. Therefore, we decided that 
the Plan does not have to pay for definitive drug testing (G0483) provided on August 3, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the computed tomographic (CT) angiography (71275) provided on May 
22, 2022. 
 
You asked the Plan to pay for the CT angiography. The Plan denied your request. The Plan says that this is a 
duplicate service. 
 
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. The records provided do not show that another unit of code 71275 was provided 
and paid for the date of service in question. Without supporting documentation, the Plan's denial cannot be 
substantiated. Therefore, we decided that the Plan has to pay for the computed tomographic (CT) angiography 
(71275) provided on May 22, 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 lab services provided on August 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. The Plan states the test has not 
been cleared or approved by the Food and Drug Administration (FDA) and is not a companion diagnostic for 
any therapy. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on May 11, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that postoperative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. The file shows that procedure codes 33235 and 33233 billed for May 
11, 2022 were related to major surgical procedure code 33228 billed on May 29, 2022. Payment for these 
services is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for 
the surgical services rendered on May 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve suction-assisted lipectomy (liposuction). 
 
You asked the Plan to pre-approve suction-assisted lipectomy (liposuction). You say that the requested suction-
assisted lipectomy (liposuction) is medically necessary. The Plan denied your request. The Plan says the 
requested suction-assisted lipectomy (liposuction) 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 suction-assisted lipectomy 
(liposuction). Our reviewer says that the requested suction-assisted lipectomy (liposuction) is not medically 
necessary. Our physician reviewer found the record indicates that the enrollee has a distant history of breast 
cancer with TRAM flap reconstruction and subsequently required component separation for hernia repair. The 
provided records do not indicate a functional impairment. The record indicates that the requested procedure is 
for asymmetry of appearance. The requested procedure is cosmetic in nature. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. The requested service is not 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 suction-assisted lipectomy (liposuction) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve suction-assisted lipectomy (liposuction).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of permanent a cardiac 
contractility modulation (CCM) system. 
 
You asked the Plan to pre-approve insertion or replacement of permanent a CCM system. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria have not been met. 
 
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 insertion or replacement of permanent a 
CCM system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found it is premature to presume clinical outcomes and benefit. 
At the current time, the CCM system is not considered to be medically necessary in this 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 insertion or replacement of permanent a CCM system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion or replacement of permanent a 
cardiac contractility modulation (CCM) system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 16, 
2022. 
 
You asked the Plan to pay for procedure code 86077. 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 86077 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 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan services. 
 
You asked the Plan to pre-approve the PET scan. You say that the records provided support the need for the 
PET scan. The Plan denied your request. The Plan says the medical records provided do not indicate that the 
enrollee meets the diagnostic criteria for both Alzheimer's disease and frontotemporal dementia. The Plan says 
that there is no indication that the exam is being requested in the context of a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that an FDG PET scan is covered when medically 
reasonable and necessary for patients who meet the diagnostic criteria for both AD and FTD.  
 
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 for a PET scan. Our reviewer says that the criteria for 
coverage have not been met. Our physician reviewer found the records provided only indicate the presence of 
mild cognitive impairment (MCI.) There was no evidence of a diagnosis of either AD or FTD on clinical 
evaluation. 
 
We looked at this physicians review, the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve positron emission tomography (PET) scan services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an axillary nerve block (64417) and suprascapular nerve 
block (64418). 
 
You asked the Plan to pre-approve the nerve blocks. You say that the requested nerve blocks are medically 
necessary for the enrollee. The Plan denied your request. The Plan says the requested nerve blocks are 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 the nerve blocks. Our reviewer says that 
the nerve blocks are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no literature to support that a series of nerve blocks is effective in dealing with chronic pain. 
Therefore, the reviewer found that the requested nerve blocks are not medically reasonable and 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 the nerve blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an axillary nerve block (64417) and suprascapular nerve block (64418).