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

 
We decided that the Plan does not have to pre-approve treatment with Stelara (J3358). 
 
You asked the Plan to pre-approve Stelara. You say that the requested drug is a medical necessity for you. 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 Stelara. 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 steroids or infliximab before they will approve the requested drug, Stelara. Based on the 
medical records provided, there is no indication that you have 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 drug(s) would likely be less effective and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Stelara have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Stelara (J3358).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 20, 2022, billed with 
codes 81162, 81201, 81292, 81295, 81298, 81314, 81317, 81334 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary and 
appropriate. 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 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 
June 20, 2022, billed with codes 81162, 81201, 81292, 81295, 81298, 81314, 81317, 81334 and 81351.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93042 and 99053 billed for date of service 
March 28, 2022. 
 
You asked the Plan to pay for procedure codes 93042 and 99053. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says payment for code 93042 is bundled into payment 
for code 93010. The Plan also says that procedure code 99053 is considered bundled and 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, we have confirmed that code 93042 is a column II code to column I code 93010. This claim has 
not been billed with an appropriate modifier to bypass the edit. We also find that procedure code 99053 has a 
status indicator of B on the Physician Fee Schedule. This means that procedure code 99053 is not separately 
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 codes 93042 and 99053 billed for date of service March 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and urinalysis provided on September 29, 
2022. 
 
You asked the Plan to pay for an office visit and urinalysis. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit and 
urinalysis provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95012 billed for date of service July 15, 
2022. 
 
You asked the Plan to pay for procedure code 95012. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a PC/TC indicator of 5 identifies services for 
which payment may not be made when the services are provided to hospital inpatients or patients in a hospital 
outpatient department. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 95012 have not been met. Specifically, the services at issue have been billed with 
Place of Service (POS) code 22, indicating an outpatient hospital. Therefore, we decided that the Plan does not 
have to pay for procedure code 95012 billed for date of service July 15, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0482) provided on August 30, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were reported correctly. The Plan 
denied your request. The Plan says that the medical records do not support the code used to report these 
services. 
 
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 G0482 is drug test(s), definitive, 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the records support that 20 drug 
classes were tested in this case, including alcohol biomarkers, amphetamines, benzodiazepines, buprenorphine, 
cannabinoids (natural), cocaine, fentanyls, gabapentin (non-blood), heroin metabolite, methadone, 
methylenedioxyamphetamines, methylphenidate, opiates, opioids and opiate analogs, oxycodone, 
phencyclidine, pregabalin, skeletal muscle relaxants, tapentadol and tramadol. Based on this information, we 
decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan 
has to pay for definitive drug testing (G0482) provided on August 30, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 44145 and 44120 billed for February 24, 
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 procedure codes 44145 and 44120 are not supported. 
 
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 44145 is colectomy, partial; with coloproctostomy (low 
pelvic anastomosis). The definition of code 44120 is enterectomy, resection of small intestine; single resection 
and anastomosis. 
 
We find that CPT codes 44145 and 44120 are not supported in the medical record. Specifically, there is no 
documentation of a partial colectomy with coloproctostomy for code 44145. There is no documentation of an 
enterectomy after resection of small intenstine for a single resection and anastomosis for code 44120. 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 procedure codes 44145 and 44120 billed for February 24, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator provided on August 14, 2022. 
 
You asked the Plan to pay for the device. The Plan denied your request. The Plan says the proof of delivery is 
not itemized to indicate the specific supplies. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The packing slip 
provided is dated October 14, 2022, and the delivery ticket is dated July 18, 2022. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulator provided on August 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient left total knee arthroplasty, right (27447). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that the enrollee has met and surpassed 
the guidelines to have this surgery. The Plan denied your request. The Plan says an outpatient left total knee 
arthroplasty is 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 outpatient procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding a trial and failure of recent, 
reasonable, comprehensive less invasive conservative care measures. The recent cortisone injection was 
provided on December 21, 2022, with no follow-up examination provided to corroborate failure. The 
December 27, 2022 physical therapy did indicate that she would benefit from formal therapy. Moreover, the 
enrollees body mass index, height, or weight was not documented on the documentation provided for review. 
There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in 
this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested left total knee arthroplasty (CPT 
27447), in this case, 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 the outpatient procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve outpatient left total knee arthroplasty, right (27447).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
March 4, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 99310 is Subsequent nursing facility care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive 
interval history; A comprehensive examination; 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. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. 
Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit. 
 
We find that CPT code 99310 is not supported in the medical record. Specifically, the enrollee was seen for a 
follow-up evaluation in an assisted living facility. There is a more appropriate code to be billed for the services 
rendered. Based on this information, we decided that Medicare rules for coverage of the subsequent nursing 
facility care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
subsequent nursing facility care services provided on March 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy (93704 x 4). 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. You say that these services are medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the requested services are not 
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 bioimpedance spectroscopy. Our 
reviewer says that the requested bioimpedance spectroscopy are considered medically reasonable and necessary 
in this case. Our physician reviewer found the medical literature indicates that bioimpedance analysis is a 
potential tool with demonstrated benefits for prevention of chronic breast cancer-related lymphedema (BCRL) 
and may be an economic and great alternative for early diagnosis of BCRL. Therefore, the reviewer found that 
the requested treatment is 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 bioimpedance spectroscopy have been met. Therefore, we decided that the Plan 
has to pre-approve bioimpedance spectroscopy (93704 x 4).  
 
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 procedure code 99153 billed for date of service June 23, 
2022. 
 You asked the Plan to pay for procedure code 99153. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This indicator 
identifies stand-alone codes that describe 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. Modifiers 26 and TC cannot be used with these codes. Code 99153 is not payable as 
billed. Based on this information, we decided that Medicare rules for coverage of procedure code 99153 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed for 
date of service June 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric services provided July 17, 2022, to 
August 2, 2022. 
 
You asked the Plan to pay for the inpatient psychiatric services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
 
 We find that the inpatient psychiatric services are not supported in the medical record. Specifically, this claim 
was not billed with a correct taxonomy code. Based on this information, we decided that Medicare rules for 
coverage of the inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient psychiatric services provided July 17, 2022, to August 2, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for computed tomography, head or brain; without contrast material, billed 
on October 7, 2022. 
 
You asked the Plan to pay for radiology services billed. You say that the claim was billed correctly and should 
be paid. The Plan denied your request. The Plan says that this code is bundled to code 0042T. 
 
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 70450 is computed tomography, head or brain; without contrast material. 
 
We find that CPT code 70450 is supported in the medical record. Specifically, there is no active NCCI edit that 
bundles this code to 0042T. Based on this information, we decided that Medicare rules for coverage of 
radiology services billed have been met. Therefore, we decided that the Plan has to pay for computed 
tomography, head or brain; without contrast material, billed on October 7, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 
23, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal cord stimulator trial. 
 
You asked the Plan to pre-approve the spinal cord stimulator trial. You say that you are very upset for this 
request being denied. You are disabled and using a walker, and on pain medications due to constant pain. The 
Plan denied your request. The Plan says the enrollee must undergo appropriate psychological screening prior to 
spinal cord stimulator trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the spinal cord stimulator trial as part of a clinical trial. The Plan 
does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does 
not have to pre-approve the spinal cord stimulator trial.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88321 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code 88321. You say that you would like the Plan to reconsider their 
denial of payment. 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 88321 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 88321 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 88321 billed for date of service October 4, 2022.