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

 
We decided that the Plan does not have to pay for procedure code 77001 billed for date of service February 23, 
2022. 
 You asked the Plan to pay for procedure code 77001. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says payment for code 77001 is bundled into payment for code 
36573. 
 
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 77001 
is a column II code to column I code 36573. 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 77001 billed for date of service February 23, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (procedure code 99285) 
provided to the enrollee on August 31, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says changing to CPT 99284 was appropriate in this case. 
 
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 99285 is [*****enter CPT Codebook definition*****]. 
 
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 in this case, documentation 
support a comprehensive history; comprehensive exam and medical decision making of moderate complexity 
(laboratory, radiology and EKG procedures), therefore documentation supports CPT 99284. 
 
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 emergency department services (procedure code 99285) provided to the enrollee on August 31, 
2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 You asked the Plan to pre-approve implantable loop recorder. You say that when the enrollee was in the 
hospital, they had a 72-hour telemetry negative monitor. Due to the enrollee's age and all symptoms, you are 
wanting to do the loop as soon as possible. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare criteria for an ILR. An implantable loop recorder 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 implantable loop recorder. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee had no history of atrial fibrillation, nor were any significant 
cardiac arrhythmias noted on ECG monitoring. A recent randomized clinical trial found that continuous 
monitoring for atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial 
fibrillation was detected) was not superior to usual care in reducing stroke or systemic embolism among 
patients at high risk of stroke but without a known prior history of atrial fibrillation (1). At this time, insertion 
of an ILR would not be considered medically appropriate and necessary in this enrollees 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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Insertion, subcutaneous cardiac rhythm monitor, including programming 
(33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27096 billed for date of service January 5, 
2022. 
 
You asked the Plan to pay for procedure code 27096. You say that the service was medically necessary. 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 27096 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 27096 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 27096 billed for date of service January 5, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve laparoscopic sleeve gastrectomy for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that bariatric surgery for treatment of comorbid 
conditions related to morbid obesity is covered under specific circumstances. 
 
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 surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has been cleared for surgery from a cardiac standpoint and a renal standpoint. The 
enrollee has a body mass index of 35kg/m2 or higher. The enrollee has a diagnosis of severe obesity, with 
comorbidities including a longstanding history of type 2 diabetes with diabetic nephropathy, and mixed 
hyperlipidemia. The enrollee has tried multiple diets, commercial and other, without long-term success. The 
enrollee has seen a nutritionist, an exercise physiologist, and has undergone psychological evaluation with 
behavioral health. The enrollee has been previously unsuccessful with medical treatment for obesity. 
 
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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve laparoscopic sleeve gastrectomy for the enrollee.  
 
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 Tempus Liquid Biopsy panel (81455) billed for date of 
service April 18, 2022. You asked the Plan to pay for the liquid laboratory testing. You say that this test was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says the specimen was collected on 
April 8, 2022, which is inconsistent with the date of service billed. Medicare rules say that laboratory services 
should generally be reported with the date of specimen collection as the date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date the specimen was collected as the date of service.  
 
We looked at the file and Medicare rules.  The record shows that the specimen was collected on April 8, 2022, 
rather than the billed date of service of April 18, 2022. The records provided do not indicate that an exception 
to the general rule has been met in this case, which means that the correct date of service would be April 8, 
2022. Based on this information, we decided that Medicare rules for coverage of the liquid laboratory testing 
have not been met. Therefore, we decided that the Plan does not have to pay for Tempus Liquid Biopsy panel 
(81455) billed for date of service April 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit and drug test provided on March 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for office visit and drug test. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
  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 office visit and drug test provided on March 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve office visit. You say that another physician declined consultation due to not 
performing surgery. The Plan denied your request. The Plan says this provider is out-of-network with the Plan 
and you can be treated by an in-network physician. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 20692, 27707) provided to 
the enrollee on February 18, 2022. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the denied codes cannot be verified. 
 
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 20692: 
 
Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, 
Ilizarov, Monticelli type) 
 
 
 CPT 27707: 
 
Osteotomy; fibula 
 
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 operative narrative states the 
tibia was sitting posterior relative to the talus. The frame was then brought into the field and positioned the leg 
appropriately. An anterior to posterior external fixator pin to help pull the tibia anteriorly was applied. The tibia 
was simultaneously pulled laterally to reduce the tibiotalar joint in the coronal plane. This needed to be 
performed to allow for the correct alignment for the more comprehensive total ankle arthroplasty. Therefore, 
the records do not support that CPT 20692: application of multiplane (pins or wires in more than 1 plane), 
unilateral, external fixation system (e.g., Ilizarov, Monticelli type) is a separate and distinct procedure from 
CPT 27702  ankle arthroplasty with implant (total ankle). Additionally, the operative narrative states a short 
oblique osteotomy from proximal posterior to distal anterior with the handheld sagittal saw and the distal fibula 
was positioned such that the anterior exiting portion of the osteotomy was approximately 1cm proximal to the 
tibiotalar joint line. The distal osteotomy site was then carefully peeled away from soft tissue attachment 
utilizing a Cobb elevator and knife. This needed to be performed prior to the more comprehensive total ankle 
arthroplasty. Therefore, the records do not support that CPT 27707: osteotomy, fibula is a separate and distinct 
procedure from CPT 27702  ankle arthroplasty with implant (total ankle). 
 
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 surgical services (procedure code 20692, 27707) provided to the enrollee on February 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 on date of service 
January 11, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed with code 83789 on date of service January 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says there was no clinical evidence to support the Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. The requested additional visits are not medically reasonable or necessary. Our physician reviewer 
found that the most recent documentation dated 10 10 2022 indicated that the patient has full range of motion at 
the hips and knees and nearly full motor strength in the lower limbs. She can walk 0.5 to 1.5 miles 
independently. At this point, she can continue to improve her strength and endurance with a home exercise 
program and does not require the services of a skilled physical therapist. Therefore, the 10 visits of additional 
visits of physical therapy are not medically 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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne Liquid CDx (0239U) billed for date of 
service April 15, 2022. 
 You asked the Plan to pay for FoundationOne Liquid CDx testing. You say that this test was medically 
necessary and is supported in the records provided. The Plan denied your request. The Plan says this claim was 
billed with an incorrect date of service, as the record shows that the specimen was collected on April 7, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be billed 
with the date of specimen collection reported as the date of service. 
 
We looked at the file and Medicare rules. The records provided do not show that an exception to the general 
rule has been met in this case. The records show that although the test was performed on April 15, 2022, the 
specimen used for this test was collected on April 7, 2022. Medicare rules say that April 7, 2022, is the correct 
date to report in this case. Based on this information, we decided that Medicare rules for coverage of 
FoundationOne Liquid CDx testing have not been met. Therefore, we decided that the Plan does not have to 
pay for FoundationOne Liquid CDx (0239U) billed for date of service April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 4, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on May 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis with exploration of spinal fusion for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no clinical justification for both fusion surgery and exploration of fusion in this case. The 
enrollee has only had several weeks of documented low back pain symptoms, and there are no red flags for 
surgery documented. There is no documented instability or hardware complications. Surgery not clinically 
needed at this time. More conservative measures for back pain such as physical therapy are appropriate 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis with exploration of spinal fusion for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided April 8, 2022. 
 
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 this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
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, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for lab services (83789) provided April 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you still have a drain from a surgical procedure that 
needs follow up and other concerns. The Plan denied your request. The Plan says the enrollee at this time is 
medically stable and no longer appears to meet guidelines for continued stay. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found although records document the enrollee is still limited functionally, provided records 
do not document that further therapy needs could not be managed by home health services, in a long-term care 
setting or in the out-patient setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.