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

 
We decided that the Plan does not have to pay for drug testing (G0482) provided on September 12, 2022. 
 
You asked the Plan to pay for the drug testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed 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 Testing, definitive, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records provided do not 
show that at least 15 drug classes were tested. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
drug testing (G0482) provided on September 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 19, 2022, to 
April 17, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this should be paid for. 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 March 19, 2022, to April 
17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307) provided on June 7, 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 the billed code 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 80307 is not supported in the medical record. Specifically, this code was previously 
paid on January 4, 2023. The provided records do not support multiple instances of this code. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (80307) provided on June 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dronabinol. 
 
You asked the Plan to pre-approve Dronabinol. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that oral anti-emetic drugs that are used as full 
replacement for intravenous dosage forms of a cancer regimen are covered under specific circumstances. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Dronabinol have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Dronabinol.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound-guided radiation therapy (US-IGRT). 
 
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 the treatment itself is not disputed in this case but rather the need for image guidance. Usually, IGRT 
is used when critical structures are abutting or in close proximity to the target that is being treated to high 
doses. This situation does not apply to this patient for which the target lesion can be seen on the skin to assist in 
daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being 
treated. Certainly, using ultrasound on a daily basis is not unreasonable to offer but not necessary. Billing for 
daily IGRT which would not be furnished in accordance with accepted standards of medical practice. 
 
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 ultrasound-guided radiation therapy (US-IGRT).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (73090) provided on August 1, 2022. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 73090 is not supported in the medical record. Specifically, records show this service 
was performed on the lower left extremity. The claim was not billed with the required anatomical modifier. 
Based on this information, we decided that Medicare rules for coverage of the radiology services have not been 
met. Therefore, we decided that the Plan does not have to pay for radiology services (73090) provided on 
August 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 63056) provided to the 
enrollee on September 9, 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 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 code 63056 is "Transpedicular approach with decompression 
of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including 
transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)." 
 
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 there is no documentation in the 
operative note of transpedicular decompression. The code 63056 should not be approved. 
 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 63056) provided to the enrollee on September 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genvisc 850. 
 
You asked the Plan to pre-approve the drug. You say that this is needed. The Plan denied your request. The 
Plan says there is no reason the preferred drugs cannot be used. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the provided 
records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record 
does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's 
preferred step one alternative. The elements of the coverage criteria are not satisfied.  
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Genvisc 850.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on November 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on July 9, 2021, to July 
11, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code I50.23, described as acute 
on chronic systolic (congestive) heart failure. 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that documentation does not support 
the billed code. Our physician reviewer found that the enrollee is an 85-year-old female who was treated in the 
hospital. Physical findings were not significant for wheezing or rales. Chest x-ray showed some pulmonary 
edema. On admission, she denied further shortness of breath, peripheral edema, or other clinical signs of acute 
congestive heart failure to support this diagnosis for this admission. Throughout the hospital stay she continued 
without signs or symptoms of acute on chronic congestive heart failure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on July 9, 2021, to July 11, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 31, 2022, billed with 
codes 81345. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. 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 
August 31, 2022, billed with codes 81345.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for angiography services (procedure code 75726, 75774) rendered on 
September 20, 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 75726: 
 
Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision 
and interpretation 
 
CPT 75774: 
 
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 
interpretation (List separately in addition to code for primary procedure) 
 
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 the documentation supports coverage 
of the codes in question. Diagnostic angiography performed in preparation for embolization is separately 
billable and not bundled in the code for embolization. CPT 75726 codes for angiography of a visceral vessel. In 
this case the celiac artery was engaged and imaged with satisfactory documentation of the findings. In terms of 
CPT 75774, this codes for angiography of an additional vessel provided that there was a repositioning of the 
catheter.  There is satisfactory documentation that the catheter was repositioned to engage and image via the 
common hepatic artery. There is satisfactory documentation of the angiography findings. Both of the codes 
were rendered as separaten and distinct from CPT 37243. 
 
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 
angiography services (procedure code 75726, 75774) rendered on September 20, 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 CX Bladder Detect test (0012M) provided on April 25, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for CX Bladder Detect test. You say that you appreciate prompt review of this 
information and authorization of coverage for the CX Bladder detect test for this enrollee. The Plan denied 
your request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered.  
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. Also, the CX Bladder panel remains unproven at this time. 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 CX Bladder Detect test (0012M) provided on April 25, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (A9276, A9277). 
 
You asked the Plan to pre-approve a CGM. You say that you are type 2 diabetic and are insulin dependent. You 
were pricking your finger three times a day which gave you an infection on one of your fingers. You need the 
requested CGM. The Plan denied your request. The Plan says you do not require three or more daily injections 
of insulin; therefore, you do not meet criteria for approval of the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM) (A9276, A9277).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided superficial radiation therapy. 
 
You asked the Plan to pre-approve the services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
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 the treatment itself is not disputed in this case but rather the need for image guidance. Usually, 
image-guided radiation therapy (IGRT) is used when critical structures are abutting or in close proximity to the 
target that is being treated to high doses. This situation does not apply to this patient for which the target lesion 
can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for 
IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable 
to offer but not necessary. Billing for daily IGRT which would not be furnished in accordance with accepted 
standards of medical practice." 
 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 image-guided superficial radiation therapy.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for 76856. We decided that the Plan does not have to pay for 93976.  
 
You asked the Plan to pay for radiological services provided on September 22, 2022. You say that the claim 
was billed correctly and should be paid. The Plan says that documentation does not support the billed code. 
 We decided that the Plan has to pay for 76856.  
 
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 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 code 76856, described as ultrasound, pelvic (nonobstetric), 
real time with image documentation; complete. Our reviewer says that documentation does support the billed 
code. Our reviewer found the enrollee was a then, 66-year-old female who was hospitalized with vaginal 
bleeding on September 22, 2022. She underwent a pelvic ultrasound.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 76856 have been met. 
 
Therefore, we decided that the Plan has to pay for 76856.  
 
We also decided that the Plan does not have to pay for 93976. 
 
The Plan must follow Medicare rules. The 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 93976 is a 
column II code to column I code 76856. Our reviewer says that the use of modifier -59 is not supported by the 
documentation. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code(s) 93976. 
 
Therefore, we decided that the Plan does not have to pay for 93976. 
 
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.