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

 
We decided that the Plan does not have to pay for an x-ray (71045) provided on January 18, 2022. 
 
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your 
request. The Plan says this is not documented. 
 
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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a x-ray (71045) provided on January 18, 2022, have been met. The submitted medical records do not include documentation of an x-ray performed 
or interpreted by the provider billed on the claim. Therefore, we decided that the Plan does not have to pay for 
an x-ray (71045) provided on January 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81551) provided November 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered for males aged 40 to 85 
years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being 
considered for a repeat biopsy. 
 
We looked at the file and Medicare rules. This test was performed at the time of the initial biopsy. There was 
no record of a previous negative biopsy or consideration for a second biopsy. 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 lab services (81551) provided November 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast ultrasound (76642), diagnostic mammography 
(77066) and diagnostic digital breast tomosynthesis (G0279) provided on January 5, 2022. 
 You asked the Plan to pay for the breast ultrasound, diagnostic mammography and diagnostic digital breast 
tomosynthesis.. You say that you would like reconsideration based on the records submitted. The Plan denied 
your request. The Plan says these codes exceed the MUE. 
 
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 codes 77066 and G0279 is 1. The MAI value for these codes is 2. You billed 2 
units of these codes, exceeding the MUE.Additionally, the MUE for CPT code 76642 is 2. The MAI value for 
this code is 2. You billed 4 units of this code, exceeding the MUE. Based on this information, we decided that 
Medicare rules for coverage of the breast ultrasound, diagnostic mammography and diagnostic digital breast 
tomosynthesis. have not been met. Therefore, we decided that the Plan does not have to pay for the breast 
ultrasound (76642), diagnostic mammography (77066) and diagnostic digital breast tomosynthesis (G0279) 
provided on January 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
October 8, 2019. 
 
You asked the Plan to pay for hospital discharge management. You say that this service was billed 
appropriately. The Plan denied your request. The Plan says this service is not supported in the medical record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99239 is hospital discharge day management; more than 30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the record. Based on this information, we decided that Medicare rules for coverage of 
hospital discharge management have not been met. Therefore, we decided that the Plan does not have to pay 
for hospital discharge day management (99239) provided on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supply allowance used with a therapeutic CGM device 
(K0553) and receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system 
(K0554) provided November 4, 2021. 
 
You asked the Plan to pay for the CGM device and supplies. You say that you are a DME company that sends 
directly to the enrollee's home every 30 days, supply refill which is approved by Medicare. The Plan denied your request. The Plan says the documentation submitted do not support the billed supply code. Evidence of 
misrepresented services. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM device and supplies. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that the member has diabetes mellitus. The enrollee is not 
insulin treated with three or more daily administrations of insulin or a Medicare-covered continuous 
subcutaneous insulin infusion pump. The enrollees insulin treatment regimen does not require frequent 
adjustment by the beneficiary on the basis of BGM or CGM testing results. 
 
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 CGM device and supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for supply allowance used with a therapeutic CGM device (K0553) and receiver 
(monitor), dedicated, for use with therapeutic glucose continuous monitor system (K0554) provided November 
4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on September 15, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the genetic testing services provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Percutaneous injection. 
 
You asked the Plan to pre-approve a Percutaneous injection. You say that a Percutaneous injection is medically 
necessary. The Plan denied your request. The Plan says a Percutaneous injection does not meet the Plan's 
Medical Policy coverage criteria. 
 
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 Percutaneous injection. Our reviewer 
says that a Percutaneous injection is not medically necessary. Our physician reviewer found that the provider is 
requesting the injection of VIA Disc allograft into the spinal disc for advanced degenerative disc disease 
against the Food and Drug Administration (FDA) approval guidelines. Large well-designed studies in the peer 
review scientific literature comparing stand-alone use of VIA Disc allograft to established treatments are 
needed. Published studies do not demonstrate any long-term health outcome advantage with the use of  
VIA Disc NP allograft as an alternative to standard treatments. The review has determined that the service at 
issue is not medically reasonable or 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 a Percutaneous injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Percutaneous injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81210, 81235, 81272, 81275, 81276, 
81292, 81301, 81311, 81321) provided September 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. In this case, multiple unbundled codes were submitted for a single 
genetic testing panel. 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 lab services (81206, 81210, 81235, 81272, 81275, 
81276, 81292, 81301, 81311, 81321) provided September 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aflibercept injection rendered on February 7, 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 claim was not billed with the required drug administration code. 
 
The Plan must follow Medicare rules. The rules say that aflibercept must be billed with CPT code 67028 
(intravitreal injection of a pharmacologic agent). 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required 
CPT code 67028. 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 aflibercept injection 
rendered on February 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from June 26, 2020, to July 
2, 2020, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care billed with DRG 871. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not 
appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 291 is more appropriate in this case. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
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 inpatient care billed with DRG 871. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical records 
for this inpatient admission. Our physician reviewer found that the documentation supports an admission for 
hypertensive heart disease with heart failure. From the information that was received, documentation was 
inconsistent regarding a diagnosis of sepsis. Even though sepsis is noted on a physician query, supporting 
medical record documentation was not found within the record. This was an enrollee with a past medical 
history of diabetes, hypertension, and congestive heart failure who presented with complaints of leg swelling 
and shortness of breath. Per emergency room provider exam, "he is not in acute distress". The course 
documentation also notes that, "vital signs stable on arrival" and "labs unremarkable". The enrollee was 
admitted for acute on chronic systolic congestive heart failure. The review has determined that the medical 
records did not support the billing of sepsis, unspecified organism (A41.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 871 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from June 26, 2020, to July 2, 2020, as 
billed with Diagnosis Related Group (DRG) 871.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says he facet joint injections do not meet the Medicare LCD 
coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that in this case, there was 
an extended period of time, two years or more, since the last RFA (in 2017) and/or there is a question as to the 
source of the recurrent pain then diagnostic procedures must be repeated. However, according to the coverage 
criteria, one to two levels, either unilateral or bilateral, are allowed per session per spine region. The need for a 
three or four-level procedure bilaterally may be considered under unique circumstances and with sufficient 
documentation of medical necessity on appeal. A session is a time period, which includes all procedures (i.e., 
MBB, IA, facet cyst ruptures, and RFA ablations) that are performed during the same day. The requested left 
L3-L4, L4-L5, L5-S1, S1 (4 levels unilaterally) are not medically reasonable or necessary according to the 
criteria established in the above 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve percutaneous vertebral augmentation including cavity creation 
using mechanical device of one vertebral body (22514). 
 
You asked the Plan to pre-approve T2 Kyphoplasty. You say that the service is medically necessary in treating 
the enrollee's pain due to the compression fracture at L2. The Plan denied your request. The Plan says that the 
records do not support that this service is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 T2 Kyphoplasty. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has low back pain. On CT scan a 20-25% compression fracture of L2 is reported. It is specifically stated that it is "mild acute". The request meets the criteria for a kyphoplasty and is deemed 
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 T2 Kyphoplasty have been met. Therefore, we decided that the Plan has to pre-
approve percutaneous vertebral augmentation including cavity creation using mechanical device of one 
vertebral body (22514).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a paring of benign lesion (11056) and a nail debridement 
(11721) provided on December 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a paring of benign lesion and a nail debridement. You say that the services at 
issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment 
for out-of-network care have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a paring of benign lesion (11056) and a nail 
debridement (11721) provided on December 3, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Oxymetazoline solution provided on January 18, 2022. 
 
You asked the Plan to pay for the Oxymetazoline solution. You say that you understand Afrin is an over-the-
counter medication, but the physician used the spray and you believe it should be covered. The Plan denied 
your request. The Plan says the Oxymetazoline solution is a self-administered drug and is not covered under 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Oxymetazoline solution 
provided on January 18, 2022.  
 
Benefits for the Oxymetazoline solution may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22514 billed for date of service December 
21, 2021. 
 
You asked the Plan to pay for procedure code 22514. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 22514 is bundled into payment for code 22513. 
 
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 22514 
is a column II code to column I code 22513 with a modifier indicator of 0. This means that no modifier can be 
appended to allow for payment. The column II code is therefore not payable. 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 22514 billed for date of service December 21, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99232-25 billed for date of service May 21, 2021. 
 
You asked the Plan to pay for code 99232-25. You say that this code should be separately payable. The Plan 
denied your request. The Plan says that this code is not separately payable based on National Correct Coding 
Initiative (NCCI) edits. 
 
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 Plans sole denial rationale is that separate payment for code 99232-25 is 
not made because it is incidental.  However, the Plan has failed to identify to which other code 99232-25 is 
considered incidental.  Furthermore, this code was billed with a -25 modifier, which indicates that the service 
was separate and distinct from other services performed on that date of service.  The Plan has failed to address 
the -25 modifier at all in its brief denial rationale. The only claim information submitted in the case file to us by 
the Plan shows that the only other code billed for this date of service was 93451.  According to the NCCI, 
modifiers are permitted for this code pair.  A modifier was billed in this case.  Without any explanation from 
the Plan regarding which code was the primary code or whether or not the modifier was considered, we 
cannot determine if the Plans denial was appropriate. The burden is on the Plan to show why its denial was 
appropriate, and they have failed to do so here. Therefore, we decided that the Plan has to pay for code 99232-
25 billed for date of service May 21, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.