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

 
We decided that the Plan does not have to pay for the laboratory test (87507) provided on December 20, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was necessary and is supported in the 
medical record. The Plan denied your request. The Plan says the claim for this molecular pathology testing did 
not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (87507) 
provided on December 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provide on July 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was not 
billed with the appropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that the claim must include modifier GN, GO, or GP 
to distinguish the discipline of the plan of care under which the service is delivered. 
 
We looked at the file and Medicare rules. The therapy services in this case were not billed with the appropriate 
modifier as required by Medicare rules. This causes the entire claim to deny. 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 the services provide on July 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for echocardiographic imaging (93319) billed for date of service 
August 30, 2022. 
 
You asked the Plan to pay for echocardiographic imaging. You say that you billed the service at issue correctly. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a PC/TC indicator of 0 indicates a physician 
service code. Physician services cannot be split into professional and technical components. Modifiers 26 & TC 
cannot be used with these codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of echocardiographic imaging have not been met. Specifically, the service at issue was reported with modifier 26. Therefore, we decided that the Plan does not have to pay for echocardiographic imaging (93319) 
billed for date of service August 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgery provided on March 8, 2023. 
 
You asked the Plan to waive the copayment for the surgery. You say that you received poor care and should not 
have to pay. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for each outpatient surgery and/or services at an outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for the surgery. This item/service falls within the outpatient 
hospital services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the surgery provided 
on March 8, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the arthrodesis of the sacroiliac (SI) joint (27279). 
 
You asked the Plan to pre-approve the outpatient procedure. You say that the medical records provided support 
the necessity of the services in dispute. The Plan denied your request. The Plan says based on Medicare 
guidelines, the arthrodesis of the sacroiliac joint (27279) requested does not meet the requirements for 
approval.  
 
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 this enrollee was being treated for spinal instabilities of the sacral spine and 
presented with low back pain and hip and leg pain. The exam reveals a limited lumbar range of motion secondary to pain. Facet loading is positive for pain bilaterally. Facet tenderness is noted to palpation 
bilaterally. However, detailed documentation is not evident regarding imaging or radiographic evidence 
supporting a sacroiliitis pathology. There is no clear history of SI joint pain onset or failure of conservative 
treatment directed to the SI joint. There are no objective findings corroborating right SI joint pathology. 
Multiple other plausible pain generators (including at the lumbosacral spine) are evident. There are limited 
large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical 
setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested sacroiliac joint fusion, 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 arthrodesis of the sacroiliac (SI) joint (27279).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the CT scan provided on October 18, 
2022, the specialist office visit provided on October 25, 2022, the MRI provided on October 28, 2022, the ECG 
provided on November 3, 2022, and the inpatient hospital stay provided from November 7, 2022, to November 
10, 2022. 
 
You asked the Plan to waive the copayments for the CT scan, specialist office visit, MRI, ECG, and the 
inpatient care. You say that these services should be fully covered. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for each Medicare-covered CT scan. Your contract with the Plan also clearly says that you must pay 
a $25 copayment for physician specialist services. Your contract with the Plan also clearly says that you must 
pay a $300 copayment for Medicare-covered diagnostic radiology service, including MRIs. Your contract with 
the Plan also clearly says that you must pay a $25 copayment each Medicare-covered diagnostic procedure and 
test, including ECGs. Your contract with the Plan also clearly says that you must pay a $350 copayment per 
day, for days 1 to 5 and a $0 copayment per day, for days 6 to 90 for inpatient hospital stays. 
 
You have been asked to pay a $300 copayment for the CT scan provided on October 18, 2022. You have also 
been asked to pay a $300 copayment for the MRI provided on October 28, 2022. You have also been asked to 
pay a $25 copayment for the ECG provided on November 3, 2022. These items/services fall within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to 
pay a $25 copayment for the specialist office visit provided on October 25, 2022. This item/service falls within 
the physician/practitioner services, including doctors office visits benefit category. You have also been asked 
to pay a $350 copayment per day, for days 1 to 3 of the inpatient hospital stay provided from November 7, 
2022, to November 10, 2022. You have been asked to pay a total of $1,050 ($350 copayment x 3 days = 
$1,050). You have not been charged for any additional days.  This item/service falls within the inpatient 
hospital care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for the CT scan provided on 
October 18, 2022, the specialist office visit provided on October 25, 2022, the MRI provided on October 28, 
2022, the ECG provided on November 3, 2022, and the inpatient stay provided from November 7, 2022, to 
November 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization (37242). 
 
You asked the Plan to pre-approve genicular artery embolization. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational.  
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 genicular artery embolization. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found geniculate artery embolization has been employed in patients with severe knee pain 
due to osteoarthritis but continues to be considered experimental, with no long-term studies documenting its 
benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization (37242).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an electric knee, advanced foot, 
and other parts (codes L5828, L5845, L5848, L5850, L5856, L5925, L5980, and L5986). 
 
You asked the Plan to pre-approve a prosthetic leg with an electric knee, advanced foot, and other parts. The 
Plan denied your request. The Plan says the request for microprocessor knee and K3 foot does not meet 
Medicare criteria as reasonable and necessary. The Plan also says that Medicare does not cover replacement 
costs for items still under warranty. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. 
 
 
 
 
 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 prosthetic leg with an electric knee, 
advanced foot, and other parts. Our reviewer says that a prosthetic leg with an electric knee, advanced foot, and 
other parts is not medically necessary. Our physician reviewer found the documentation does not indicate that 
you are a K3 ambulator given your use of Lofstrand crutches. Your current microprocessor knee is still under 
warranty. Our reviewer also found that physician notes do not support why a microprocessor knee is needed 
over a mechanical knee for your functional needs.  
 
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 prosthetic leg with an electric knee, advanced foot, and other parts have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with an electric 
knee, advanced foot, and other parts (codes L5828, L5845, L5848, L5850, L5856, L5925, L5980, and L5986).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS). 
 
You asked the Plan to pre-approve TMS. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that repetitive transcranial magnetic stimulation (rTMS) is 
only considered medically necessary in adults who have a confirmed diagnosis of major depressive disorder 
(MDD), single or recurrent episode and meet certain criteria. 
 
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 TMS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on review of the records provided 
and utilizing Medicare criteria specifically for repetitive Transcranial Magnetic Stimulation (rTMS), a 
confirmed diagnosis to be Severe Major Depressive Disorder Single or Recurrent is required, as well as 
resistance to treatment with pharmacologic agents as evidenced by lack of clinical significant response to 4 
trials of pharmacologic agents in the current depressive episode from at least two different agent classes along 
with concurrent documented psychotherapy. Documentation presented is not specified what medications the 
enrollee had been taking during the present episode of depression. This enrollee has a diagnosis of bipolar 
disorder and therefore, does not meet the criteria for Transcranial Magnetic Stimulation (TMS). It is not 
considered 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 TMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transcranial magnetic stimulation (TMS).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing of 15-22 classes (G0482) provided on 
December 21, 2022. 
 
You asked the Plan to pay for the definitive drug testing of 15-22 classes. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says that only 9 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 the definitive drug testing of 15-22 drug classes. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, we reviewed the lab report and 
found that 15-22 drug classes were tested. Based on this information, we decided that Medicare rules for 
coverage of the definitive drug testing of 15-22 classes have been met. Therefore, we decided that the Plan has 
to pay for the definitive drug testing of 15-22 classes (G0482) provided on December 21, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to provide 5 additional home health physical therapy sessions. 
 
You asked the Plan to provide home health services. You say that you have fallen twice since hip surgery and 
need more physical therapy than once per month. The Plan denied your request. The Plan says the services are 
not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be 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 provide 5 additional home health physical therapy 
sessions. Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found that clinical documentation shows that you were discharged from home health physical therapy without any new functional status changes or diagnosis documented. Records do not show that you are home-
bound, thus the records do not show that skilled therapy services are required to effectively provide treatment, 
care, and/or services in order to improve your level of function, or to establish/perform a maintenance program 
to maintain your level of function and/or prevent deterioration in the home 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to provide 5 additional home health physical therapy sessions.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the removal of skin and tissue, and the 
application of a chemical to a wound provided by an in-network provider from December 16, 2022, to 
December 31, 2022. 
 
You asked the Plan to waive the copayment for the removal of skin and tissue and the chemical application to a 
wound. You say that these services were not outpatient surgery. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment per visit, for in-network Medicare-covered outpatient surgery. 
 
 You have been asked to pay a $250 copayment for the removal of skin and tissue and the chemical application 
to a wound. These items/services fall within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the removal of skin and tissue, and the application of a chemical to a wound provided by an in-
network provider from December 16, 2022, to December 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 12, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says payment is 
included to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that under SNF PPS all Medicare covered Part A 
services that are considered within the scope or capability of SNFs are considered paid in the PPS rate. In some 
cases, this means that the SNF must obtain some services that it does not provide directly. 
 
We looked at the file and Medicare rules. Payment for the lab services in this case is included in the skilled 
nursing facility (SNF) payment. The services are not separately payable. 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 the lab services provided on August 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that kyphoplasty is covered when specific criteria are 
met. 
 
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 there is no documentation of a brace 
trial. More conservative measures are needed. The kyphoplasty is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on dates of service from 
December 9, 2022, to January 7, 2023. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs must report value code 85 to report the 
FIPS state and county code of where the services were received. 
 
We looked at the file and Medicare rules. The number listed in value code 85 on this claim is not a valid FIPS 
code for the county in which these services were performed. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided on dates of service from December 9, 2022, to January 
7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for procedure code 95941. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service July 18, 2022.