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

 
We decided that the Plan does not have to pay for procedure codes 81334, 81405, and 81176 billed for 
December 15, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 81334, 81405, and 81176 are not supported. 
 
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 81334 is RUNX1 (runt related transcription factor 1) (eg, 
acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy) gene analysis, targeted sequence analysis (eg, exons 3-8). The definition of code 81405 is molecular pathology procedure, Level 6 (eg, 
analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 
exons, regionally targeted cytogenomic array analysis). The definition of code 81176 is ASXL1 (additional sex 
combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic 
myelomonocytic leukemia), gene analysis; targeted sequence analysis (eg, exon 12). 
 
We find that CPT codes 81334, 81405, and 81176 are not supported in the medical record. Specifically, the file 
shows that a comprehensive panel was performed and there is a more appropriate code for these services. 
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 pay for procedure codes 81334, 81405, and 81176 billed 
for December 15, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95822 billed for date of service March 3, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the billed code remains not supported. 
 
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 95822 is electroencephalogram (EEG); recording in coma 
or sleep only. We find that CPT code 95822 is not supported in the medical record. Specifically, there is a more 
comprehensive code to describe the services provided during a surgery. 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 95822 billed for date of service March 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tecentriq (atezolizumab) injection. 
 
You asked the Plan to pre-approve the Tecentriq (atezolizumab) injection. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this request does 
not meet Medicare and/or Plan policy because this mix of drugs for the enrollee's cancer is not supported by the 
Plan.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Tecentriq (atezolizumab) injection. 
Our reviewer says that the use of Tecentriq (atezolizumab) is not FDA-approved for the enrollee's diagnosis 
and is not supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. 
 
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 Tecentriq (atezolizumab) injection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Tecentriq (atezolizumab) injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service September 
22, 2022. 
 
You asked the Plan to pay for procedure code 36000. You say that this service should not be denied. The Plan 
denied your request. The Plan says procedure code 36000 is considered bundled and 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 procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service September 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care related to a reverse total 
shoulder arthroplasty and a carpal-tunnel surgery. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that acute inpatient hospital care is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says acute inpatient hospital care is 
not medically necessary. 
 
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. 
  
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found that detailed documentation is not evident in the case record regarding a 
significant past and/or current medical history that would place the enrollee at increased risk for peri-surgical 
complications requiring an inpatient stay. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care related to a reverse total shoulder arthroplasty 
and a carpal-tunnel surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from June 10, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from June 10, 2023, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from June 10, 
2023, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of June 10, 2023, forward. Our physician reviewer found the enrollee did 
not require inpatient mental health treatment beyond June 10, 2023, as he was not a danger to himself or others 
and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was 
taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollees condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from June 10, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from June 10, 2023, 
forward.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty.  
You asked the Plan to pre-approve kyphoplasty. 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 Percutaneous vertebroplasty and percutaneous 
vertebral augmentation (PVA or Kyphoplasty) procedures will be considered medically reasonable and 
necessary for certain indications. 
 
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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found there is no indication of the progression of 
vertebral body height loss, kyphotic deformity, or a severe impact on daily functioning. Therefore, the enrollee 
does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet joint injection (64633). 
 
You asked the Plan to pre-approve a facet joint injection. 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 the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and 
necessary for patients who 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 a facet joint injection. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found there is no documentation the 
provider suspects facet joint pathology. The LCD criteria have not been met. The request is deemed not 
medically reasonable and 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 a facet joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a facet joint injection (64633).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic mammography, including computer-aided 
detection (CAD) when performed (77066) and diagnostic digital breast tomosynthesis (list separately in 
addition to 77065 or 77066) provided on November 17, 2022, by an out-of-network (OON) provider.   

You asked the Plan to pay for the diagnostic services. You say that please reprocess as no changed are required. 
The Plan denied your request. The Plan says enrollee's 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. 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 diagnostic mammography, including computer-
aided detection (CAD) when performed (77066) and diagnostic digital breast tomosynthesis (list separately in 
addition to 77065 or 77066) provided on November 17, 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 an electronic connector (E2310) and a safety belt 
(E0978). 
 
You asked the Plan to pre-approve an electronic connector and a safety belt. You say that the requested items 
are medically necessary. The Plan denied your request. The Plan says that the requested power option comes 
with its own switches. The Plan also says that a seat belt is already included with the power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that if the sole function of the connection is for a 
power seat elevation or power standing feature, it will be denied as non-covered. 
 
We looked at the file and Medicare rules. An electronic connector (E2310) is not covered as the approved 
power seat elevation system comes with its own switches. The record shows that a safety belt cannot be 
requested upon initial use. A seat belt is included with the approved power wheelchair. Therefore, we decided 
that the Plan does not have to pre-approve an electronic connector (E2310) and a safety belt (E0978).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine venipuncture services (36415 x 2) and the office 
visits (99213 x 2) provided from January 29, 2021, through September 2, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
  
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the routine venipuncture services (36415 x 2) and the office visits  
(99213 x 2) provided from January 29, 2021, through September 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided on November 8, 2022. 
 
You asked the Plan to pay for SNF care. You say that the claim should be reprocessed. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for SNF care provided on November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the crown (D2740). 
 
You asked the Plan to waive the cost share for the dental services. You say that these crowns were needed to 
prevent a root canal procedure. 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 50% 
coinsurance for class three dental services.  
 
You have been asked to pay $479 coinsurance for the dental services. This item/service falls within the Dental 
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 cost share for the crown (D2740).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 84436 billed for date of service October 12, 
2022.  
 
You asked the Plan to pay for procedure code 84436. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 84436 is bundled into 
payment for code 84439. 
 
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 84436 
is a column II code to column I code 84439 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 84436 billed for date of service October 12, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97163 billed for June 28, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 97163 is not supported by the submitted records. 
 
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 97163 is physical therapy evaluation: high complexity,
requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities
that impact the plan of care; An examination of body systems using standardized tests and measures addressing
a total of 4 or more elements from any of the following: body structures and functions, activity limitations,
and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and
Clinical decision making of high complexity using standardized patient assessment instrument and/or
measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient
and/or family.
 
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 these services. Our reviewer says that procedure code 97163 
is not supported by the submitted records. Our reviewer found the records do not support that the four key 
components required for billing code 97163 are present. There is no documentation of a history of present 
problem with three or more personal factors and/or comorbidities that impact plan of care, an examination of 
body systems, a clinical presentation with unstable and unpredictable characteristics, or clinical decision 
making of high complexity. 
 
We looked at this coder'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 pay for procedure code 97163 billed for June 28, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on August 21,
2022.
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says inpatient care rather than outpatient care is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was 
provided in a less intensive setting. 
 
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 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 that the review has determined that the record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
(including earlier emergency department and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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 on August 21, 2022.