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

 
We decided that the Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary 
angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and 
interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, 
when performed (93458). 
 
You asked the Plan to pre-approve a left heart catheterization. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the left heart catheterization is not medically necessary at this time. 
 
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 left heart catheterization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found cardiac CTA in 2022 showed non-significant coronary disease. The 
medical records provided do not support the rationale for this invasive imaging study. Guidelines do not 
support a need for cardiac catheterization in this setting. As a result, at this time, cardiac catheterization would 
not be considered medically appropriate and necessary in this enrollee's clinical management. 
 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 left heart catheterization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a catheter placement in coronary artery(s) for coronary angiography, 
including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with 
left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 
(93458).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88334-26 billed for date of service October 
13, 2022. 
 You asked the Plan to pay for procedure code 88334-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 88334-26 is bundled into 
payment for code 88331-26. 
 
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 
88334-26 is a column II code to column I code 88331-26. 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 88334-26 billed for date of service 
October 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 6, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 December 6, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on September 27, 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 processed by the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
Explanation of Benefits (EOB) from the primary insurer for the claim, but a response has not been received.. 
As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the ambulance 
transport rendered on September 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (J3490) provided on October 10, 2022. 
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the code billed is 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. 
 
We find that CPT code J3490 is not supported in the medical record. Specifically, this code is included in the 
global surgery package for code 27096, which was billed for the same date of service. Based on this 
information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we 
decided that the Plan does not have to pay for injections (J3490) provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99153 billed for October 6, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 identifies technical component only stand alone codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for procedure code 99153 billed 
for October 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography, heart, without contrast 
material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve Quantitative Calcium Scoring. You say that you disagree with the denial. 
The Plan denied your request. The Plan says Medicare does not cover a screening CCTA for asymptomatic 
patients, for risk stratification or for quantitative evaluation of coronary calcium. 
 
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 Quantitative Calcium Scoring. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found numerous studies have demonstrated that coronary artery calcium (CAC) 
scoring using ultrafast cardiac CT adds predictive value in assessing risk of coronary heart disease (CHD). In 
one study a score of zero was associated with a CHD risk of 1-6%, while a CAC score over 300 was associated 
with a risk of 13-26%. Clinical studies have not, however, shown that CAC scoring adds value in clinical 
management of asymptomatic patients in whom risk factors are targeted. In summary, current evidence 
showing that the use of CAC scores in clinical management of asymptomatic individuals leads to changes in 
patient management or in individual risk behaviors that improve cardiac outputs outcomes is limited and 
inconclusive.  Overall, there is insufficient support in the peer-reviewed literature demonstrating a significant 
benefit of CT imaging of the heart with quantitative evaluation of coronary calcium in your guiding optimal 
management. As such, CT imaging of the heart without contrast material with quantitative evaluation of 
coronary calcium is considered experimental/investigational for the evaluation and management of your 
medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Quantitative Calcium Scoring have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography, heart, without contrast material, with 
quantitative evaluation of coronary calcium (75571).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is necessary for the 
enrollee due to amyotrophic lateral sclerosis. The Plan denied your request. The Plan says the request is not 
medically necessary because the records show that the requested device is to be used in a bi-level PAP mode 
(VAPS), which can be provided by another device. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has amyotrophic lateral 
sclerosis (ALS). Over the past several weeks, the enrollee has been experiencing cough and chest congestion, 
with difficulty clearing secretions. There is also increased weakness and difficulty walking, and a request for a 
wheelchair. A home ventilator has been prescribed. However, the most recent clinical visit on January 26, 
2023, describes a normal neurological examination and does not mention the need for nocturnal ventilation. 
There is no spirometry or measurement of maximum inspiratory and expiratory mouth pressures. The need for 
the home ventilator has not been documented in the medical record. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for a transcutaneous electrical nerve stimulation (tens) device, four or more 
leads, for multiple nerve stimulation provided on September 18, 2022. 
 
You asked the Plan to pay for the device. You say that this should be paid for. The Plan denied your request. 
The Plan says that Current Procedural Terminology (CPT) code E0730 remains not supported. 
 
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 plan did not respond to a request for information about clarification on the 
date of service for this case. There is evidence that this case is actually for July 18, 2022, as the delivery and 
packaging slip that was provided are for July 18, 2022. Additionally, a separate case for the same enrollee (1-
12205398466) was also for September 18, 2022 and contained a proof of delivery and packaging slip for both 
July 18, 2022, and September 18, 2022. No matter what the actual date of service is, the plan has not 
substantiated their denial in this case, as there is evidence of that the correct documentation exists for this 
device. Therefore, we decided that the Plan has to pay for a transcutaneous electrical nerve stimulation (tens) 
device, four or more leads, for multiple nerve stimulation provided on September 18, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there 
are no issues for which LTACH may offer a therapeutic advantage. The plan will continue to cover medically 
necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to an 
alternate level of care. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. 
 
 
 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that the home ventilator is being requested for use with very low set tidal volumes (150 to 200 mL) which 
could be provided by a BiPAP device with average volume assured pressure support (AVAPS) and a back-up 
rate. Ventilators used to provide BiPAP therapy are not covered. 
 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 99221. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99221 is bundled into payment for code 99223. 
 
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 99221 
is a column II code to column I code 99223 with a modifier indicator of 0. 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 99221 billed for date of service May 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 5, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. 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 December 5, 
2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services (G0481) provided on July 25, 2022. 
 
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 that the documentation does not support the billed service. 
 
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 G0481 is Drug Tests, Definitive, 8-14 drug classes. 
 
We find that CPT code G0481 is supported in the medical record. Specifically, the records provided show 
results for more than 8 drug classes. Based on this information, we decided that Medicare rules for coverage of 
the lab services have been met. Therefore, we decided that the Plan has to pay for lab services (G0481) 
provided on July 25, 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 procedure codes 87481 and 87900 rendered on December 28, 
2021. 
 
You asked the Plan to pay for the services. You say that the testing was ordered based on the treating 
physician's clinic training and medical necessity. The Plan denied your request. The Plan says the records do 
not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 
CPT 87900: 
 
Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics 
 
We asked our coder 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 reviewer found that the laboratory report does not 
include enough information to confirm this procedure has been performed. The codes cannot be verified in the 
laboratory report. 
 
We looked at this coder'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 procedure codes 87481 and 87900 rendered on December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan 
denied your request. The Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, 
E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds 
will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a total electric hospital bed (E0265).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 7, 2022. 
 
You asked the Plan to pay for the lab services. You say that your organization is legally obligated to process 
specimens sent to you, so this 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 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 July 7, 2022.