Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure codes 27005 and 27248) provided to the 
enrollee on June 29, 2022. 
 
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 that 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 27005: 
 
Tenotomy, hip flexor(s), open (separate procedure) 
 
CPT 27248: 
 
Open treatment of greater trochanteric fracture, includes internal fixation, when performed 
 
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 supported by the medical records.  
 
Our reviewer found that in terms of CPT 27005, the procedure details cite that when the femur was exposed, 
the lesser trochanter was intact and there was evidence of contracture of the iliopsoas. The iliopsoas tendon was 
released at that point in time from the lesser trochanter using electrocautery. Therefore, the CPT 27005: 
tenotomy, hip flexor(s), open (separate procedure) was documented to be rendered in this case. 
 
In terms of CPT 27248, the procedure details cite open reduction and internal fixation of the greater trochanter 
was accomplished by placing a curved introducer around the neck and the trochanter. Synthes wire was placed 
around. The open reduction and internal fixation was accomplished. Therefore, the CPT 27248: open treatment 
of greater trochanteric fracture, includes internal fixation, when performed was documented to have been 
rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure codes 27005 and 27248) provided to the enrollee on June 29, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78815 billed for date of service July 22, 
2022. 
 
You asked the Plan to pay for procedure code 78815. 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 78815 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 78815 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 78815 billed for date of service July 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation and treatment (37220, 37221, 37224, 
37225, 37226, 37227, 37228, 37229, 37230, 37231) for Peripheral Artery Disease (PAD). 
 
You asked the Plan to pre-approve consultation and treatment for PAD. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for approval of 
the requested services. The Plan also says updated testing is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that the enrollee's last test was from 2021 and that 
the symptoms are not classical for claudication. The records also show that the treating physician will bring the 
enrollee back, retest, and resubmit as necessary. Based on this information, we decided that Medicare rules for 
coverage of consultation and treatment for PAD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve consultation and treatment (37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 
37230, 37231) for Peripheral Artery Disease (PAD).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a capsule endoscopy (91110). 
 
You asked the Plan to pre-approve a capsule endoscopy. You say that the enrollee needs this test for Iron 
deficiency. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for a capsule 
endoscopy. 
 
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 capsule endoscopy. Our reviewer says 
that a capsule endoscopy is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the available records provide no documentation of gastrointestinal hemorrhage (either occult or 
visible), no laboratory evidence of iron deficiency, and no radiographic imaging of small bowel pathology. Our 
reviewer found that as such, medical appropriateness and necessity is not demonstrated for a wireless capsule 
endoscopy at this time for the enrollee. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a capsule endoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a capsule endoscopy (91110).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service September 
15, 2022. 
 
You asked the Plan to pay for the billed services. You say that the records provide evidence of medical 
necessity. The Plan denied your request. The Plan says an inappropriate place of service was 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 CPT code 85060 was billed with 22, an outpatient hospital place of service code. No payment is 
recognized for code 85060 furnished to hospital outpatients. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 85060 billed for date of service September 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88304 billed for date of service August 9, 
2022. 
 You asked the Plan to pay for procedure code 88304. You say that these services were necessary and are 
supported as billed. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88304 is 5. The MAI value for this code is 3. You billed 12 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88304 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88304 billed for date of service August 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (15-21 classes) provided to the enrollee 
on August 23, 2022. 
 
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 the documentation does not support 15-21 drug classes; only 8 drug classes were tested. 
 
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, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed." 
 
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 records do not contain 
documentation to support the coding criteria for code billed on 08/23/2022. The documentation does not 
support 15-21drug classes, only 8 drug classes were tested. 
 
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 drug testing services (15-21 classes) provided to the enrollee on August 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) (78815) and Fluorodeoxyglucose (A9552). 
 
You asked the Plan to pre-approve a PET/CT scan and Fluorodeoxyglucose. The Plan denied your request. The 
Plan says the records do not say the enrollee has cancer. The Plan also says this service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 a PET/CT scan and 
Fluorodeoxyglucose. Our reviewer says that a PET/CT scan and Fluorodeoxyglucose are not reasonable and 
necessary for the enrollee. Our physician reviewer found the porcelain gallbladder seen on ultrasound is a 
chronic finding and while there is an association of occasional gallbladder cancer with that entity further 
imaging of the gallbladder and liver is indicated prior to resorting to PET/CT. The patient's glomerular 
filtration rate (GFR) is 32 and the information provided indicates consultation with radiology shows the 
enrollee may undergo a magnetic resonance imaging (MRI) with contrast safely. Our reviewer found that such 
a study would allow further characterization of the gallbladder and liver for secondary signs of malignancy and 
would be a better test instead of the requested PET/CT. 
 
 
 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 PET/CT scan and Fluorodeoxyglucose have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) (78815) and Fluorodeoxyglucose (A9552).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 25, 2022, to 
February 23, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 25, 2022, to 
February 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myobloc. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrolle has Parkinson's disease and 
dialorrhea. She has not tried and failed the Plan's required drug, Xeomin. The records do not show that the 
required drug would be contraindicated or less effective; therefore, Myobloc is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Myobloc.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal testing (81479) provided on August 7, 
2022. 
 
You asked the Plan to pay for Guardant Reveal testing. You say that this test was medically necessary and 
appropriate for this enrollee. The Plan denied your request. The Plan says this test is not recommended by the 
National Comprehensive Cancer Network and is denied as a non-covered test. 
 
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, 
and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test 
identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that Medicare rules for coverage of Guardant Reveal testing have not been met. Therefore, we decided that the Plan 
does not have to pay for Guardant Reveal testing (81479) provided on August 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 62320 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for procedure code 62320. You say that the medical documentation submitted 
supports this procedure. The Plan denied your request. The Plan says code 62320 was billed but is not 
appropriate for the service rendered. The procedure note documented that the enrollee had C7-T1 interlaminar 
epidural steroid injection under fluoroscopic guidance performed. There is a more appropriate code(s) for 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 62320 is injection(s), of diagnostic or therapeutic 
substance(s) (e.g. anesthetic, antispamodic, opioid, steroid, other solution), not including neurolytic substances, 
including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without 
imaging or guidance. 
 
 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 procedure code 62320. Our reviewer says that procedure 
code 62320 is not supported in the medical record. Our reviewer found 62320 does not include imaging 
guidance; according to the medical record, imaging guidance was utilized to perform the epidural injection. 
There is a more appropriate code that should be reported for an epidural injection with image guidance. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 62320 billed for date of service March 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 11, 
2021, to December 13, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the enrollee did not meet inpatient 
criteria for admission. 
 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee presented to the emergency department with complaint of 
chest pain while running across the street (non-radiating, sharp, substernal, without other symptoms), which 
resolved after 10 minutes. Workup included stress test, troponin, without evidence of acute coronary syndrome 
or heart failure. Our reviewer found that the enrollee's vitals were stable, and they were asymptomatic. Our 
physician reviewer also found that it was not expected that the enrollee would have required inpatient services 
that would likely have crossed 2 midnights due to the low severity and low complexity of the presentation on 
admission. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from December 11, 2021, to 
December 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0463-HF billed for date of service July 6, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the modifier is correct for the diagnosis code 
billed. The Plan denied your request. The Plan says the modifier is not covered on an institutional claim. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code G0463 was billed with an HF modifier on an outpatient hospital facility claim. The 
code at issue was not billed with a modifier suitable for payment. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code G0463-HF billed for date of service July 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient left sacroiliac (SI) joint fusion (27279). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that your wish is that the attached 
paperwork, your medic records and records from the doctor, will be readdressed and be reconsidered so you 
can move on with your life. The Plan denied your request. The Plan says the requested surgery is not medically 
necessary and not supported by the current medical literature. 
 
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 the enrollee was being treated for sacroiliitis. The enrollee presented with back and 
extremity pain. The pain is felt throughout the left lumbar region and into the left leg. The pain stops at the foot 
with associated numbness and tingling. The pain is rated at 4-6/10. The exam reveals a positive Fortin finger 
test, tenderness to palpation over the SI joint sulcus, and posterior SI joint tenderness to palpation. Single leg 
stance does produce pain on the supporting side. Provocative tests are positive including thigh thrust, 
compression, Gaenslens, and FABER. However, detailed documentation is not evident regarding imaging corroboration of sacroiliac joint pathology. 
The MRI from April 17, 2022, noted the bilateral sacroiliac joints are normal. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested surgery in this clinical setting. 
Additionally, multiple other plausible pain generators including at the lumbosacral spine are evident. 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 outpatient sacroiliac (SI) joint fusion (CPT 27279), 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 the outpatient left sacroiliac (SI) joint fusion (27279).