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

 
We decided that the Plan does not have to pre-approve MRI of the breast. 
 
You asked the Plan to pre-approve the MRI. You say that you have a strong history of breast cancer in your 
family and your provider recommends an MRI once a year. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the 
request is not medically necessary. Our physician reviewer found that you have a history of left breast cancer in 
1988. No recurrence. Breast tissue on mammography is scattered areas of fibroglandular tissue with no 
evidence of malignancy. No imaging findings to support MRI of the breasts. No calculated risk model showing 
lifetime risk of greater than 20% going forward.  
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the breast.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service February 14, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service February 14, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure) (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatments. 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 Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not show a clear cause for the enrollee's pain. 
therefore, the reviewer found that the requested Intracept procedure 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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure) 
(64628, 64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from this care. 
The Plan denied your request. The Plan says medical records do not support the need for an LTACH 
admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services that would be offered at the LTACH that are not available at the 
current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is medically stable to transfer to SNF.  
The Plan denied your request. The Plan says that the enrollee does not meet the criteria for SNF 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has had clinically significant medical and functional status change thus 
would be expected to require ongoing assessment/treatment by skilled therapy skilled nursing. The clinical 
documentation supports daily skilled services on an inpatient basis in a skilled nursing facility. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator 
electrode array; peripheral nerve, right knee (64555x2). 
 
You asked the Plan to pre-approve a SPRINT peripheral nervous system (PNS) device. You say that the 
procedure is medically necessary. The Plan denied your request. The Plan says the requested service 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 a SPRINT peripheral nervous system 
(PNS) device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the SPRINT PNS device is experimental and 
investigational for knee pain. There is more research needed. 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 SPRINT peripheral nervous system (PNS) device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a percutaneous implantation of 
neurostimulator electrode array; peripheral nerve, right knee (64555x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 16, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service April 16, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Technetium tc-99m sestamibi (A9500) provided on October 
7, 2022. 
 
You asked the Plan to pay for Technetium tc-99m sestamibi. You say that this is supported in the records. The 
Plan denied your request. The Plan says this is not documented.  
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 A9500 is Technetium tc-99m sestamibi, diagnostic, per 
study dose. 
 
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 Technetium tc-99m sestamibi. Our reviewer says that this 
code is not supported. Our reviewer found the submitted records do not include an operative note documenting 
the billed code. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Technetium tc-99m sestamibi have not been met. Therefore, we decided that the 
Plan does not have to pay for Technetium tc-99m sestamibi (A9500) provided on October 7, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abdominoplasty. 
 
You asked the Plan to pre-approve an abdominoplasty. You say that the enrollee had a gastric sleeve, and this 
surgery would be beneficial. The Plan denied your request. The Plan says the enrollee has not met the medical 
criteria for this surgery.  
 
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 an abdominoplasty. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record provided does not establish the presence of chronic intertrigo refractory to 
appropriate medical therapy, functional impairment, or stability of weight for 18 months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an abdominoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an abdominoplasty.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has memory issues that are associated with post-concussive syndrome after motor vehicle accident. The record 
provided does not establish that the enrollee meets the diagnostic criteria of both Alzheimer's disease and 
frontotemporal dementia or that the examination is being requested in the context of a clinical trial. The 
elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0416 billed for date of service April 19, 
2023. 
 
You asked the Plan to pay for procedure code G0416. You say that this service was necessary and was reported 
appropriately. The Plan denied your request. The Plan says the diagnosis code submitted on this claim cannot 
be used as a primary diagnosis with this service. For outpatient encounters for diagnostic tests that have been 
interpreted by a physician, and the final report is available at the time of coding, code any confirmed or 
definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional 
diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code G0416 have not been met. Specifically, this was a diagnostic test which was billed 
with modifier 26 indicating that physician interpretation was provided. The records also indicate that the 
results of this procedure were available at the time of coding. However, this claim was submitted only with 
diagnosis code R97.20, which is considered a signs/symptom code. Because this was a diagnostic test which 
was interpreted by a physician, it would be more appropriate to report any confirmed or definitive diagnosis 
and not code any related signs and symptoms unless they are not routinely associated with the diagnosis. 
Therefore, we decided that the Plan does not have to pay for procedure code G0416 billed for date of service 
April 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD) (0275T). 
 
You asked the Plan to pre-approve percutaneous image-guided lumbar decompression. You say that this is 
medically necessary. The Plan denied your request. The Plan says the request is not medically necessary 
because the records show the enrollee had a minimally invasive lumbar decompression (MILD) procedure in 
the lumbar region within the past 12 months. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD is covered when provided in a clinical 
study. 
 
   
We looked at the file and Medicare rules. Exclusion criteria for the required CED study included patients that 
have received a laminectomy, laminotomy, fusion, interspinous process decompression, or MILD in the lumbar 
region during the 12 months prior to the index date. The records provided show that the enrollee received a 
bilateral MILD procedure in June 2023, which is less than 12 months ago. Because there are clear criteria that 
would exclude this enrollee from the required CED study, the NCD criteria for coverage are not met. Based on 
this information, we decided that Medicare rules for coverage of percutaneous image-guided lumbar 
decompression have not been met. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous image-guided lumbar decompression (PILD) (0275T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee replacement surgery. 
 You asked the Plan to pre-approve total knee replacement surgery. You say that the enrollee has tried and 
failed conservation treatment. The Plan denied your request. The Plan says there is no documentation of 
decreased range of motion.  
 
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 total knee replacement surgery. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. Additionally, the knee x-rays do not 
clearly indicate the grade of osteoarthritis of the right knee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of total knee replacement surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a total knee replacement surgery.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 12, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 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 81456 
is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service April 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482, & 80307) provided on January 25, 
2023. 
 
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 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 include results 
for more than 21 drug classes. Code 80307 is not payable as code 80305 was already paid for the same date of 
service. 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 (G0482, & 80307) provided 
on January 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service April 17, 
2023. 
 
You asked the Plan to pay for procedure code 81456. You say that the NCCI has agreed to change the NCCI 
indicator to One, which would allow payment for these two codes together. The Plan denied your request. The 
Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 is a column two code to column one code 81455 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Please note 
that the NCCI indicator change that you reference was not officially implemented until October 1, 2023. This 
date is well after your date of appeal. As a result, the Plan cannot be obligated to bypass this edit. You have the 
right to submit the claim again for additional consideration based on the rule change. Therefore, we decided 
that the Plan does not have to pay for procedure code 81456 billed for date of service April 17, 2023.