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

 
We decided that the Plan does not have to pay for the autonomic nervous system (ANS) function testing 
(95921, 95922) provided on April 17, 2023. 
 
You asked the Plan to pay for the ANS testing. You say that this was medically necessary for the enrollee. The 
Plan denied your request. The Plan says this was 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 pay for the ANS testing. Our reviewer says that the 
requested ANS testing is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical value and effectiveness of autonomic nervous system function testing in the setting 
of lumbar radiculopathy and low back pain has not been established in the literature. The requested test is not 
considered the standard of care for the evaluation of lumbar radiculopathy. Therefore, the reviewer found that the requested ANS testing 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 ANS testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the autonomic nervous system (ANS) function testing (95921, 95922) provided on April 17, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DCiSionRT panel rendered on May 15, 2023. 
 
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 the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that immunohistochemical panels are 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has left breast and left upper 
quadrant ductal carcinoma in situ that is ER and PR positive. There is no recommendation for Her2 testing on 
in situ breast lesions outside of a clinical trial. The routine testing of breast cancers for Ki-67 expression is not 
currently recommended by either American Society of Clinical Oncology (ASCO) or the National 
Comprehensive Cancer Network (NCCN) guidelines. Clinical guidelines have not been established for the use 
of Her2 or other biomarkers in patients with non-invasive breast neoplasia. The testing was not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the DCiSionRT panel rendered on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing, 22 or more drug class(es) (G0483) provided 
March 22, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. The medical records submitted do not include a physician order or laboratory requisition for the billed test; therefore, the service cannot be 
verified. Therefore, we decided that the Plan does not have to pay for the drug testing, 22 or more drug 
class(es) (G0483) provided March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96374, 96375, and J2250 rendered on July 
26, 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 the denied codes is: 
 
CPT 96374: 
 
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial 
substance/drug 
 
CPT 96375: 
 
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential 
intravenous push of a new substance/drug (List separately in addition to code for primary procedure) 
 
Healthcare Common Procedure Coding System (HCPCS) J2250: 
 
Injection, midazolam hydrochloride, per 1 mg 
 
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 in terms of CPT 96374 and CPT 
96375, the provider reported these codes with modifier -59. This was to indicate it as a distinct procedural 
service from CPT 64483. However, the procedure report does not include documentation to verify these codes 
as distinct from CPT 64483. Therefore, these codes and the modifier cannot be verified. 
 
In terms of J2205, the provider reported four units of service. However, the documentation describes 2mg of 
Midazolam given. The code description states that one unit is "per 1mg." Therefore, four units cannot be 
verified. 
 
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 procedure codes 96374, 96375, and J2250 rendered on July 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 You asked the Plan to pre-approve insertion of an ILR. 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 cardiac event monitors are 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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found while the enrollee has a history of 
atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation to support 
the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) and accessories 
(codes E2609, E1028, E1007, K0108, E0955, E1028, E2620, E0956, E2311). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that the DME is medically 
necessary. The Plan denied your request. The Plan says on the clinical documentation received, the coverage 
criteria are not met for the requested power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 durable medical equipment (DME). 
Our physician reviewer found the documentation available for review does not support that the enrollee 
requires a power mobility device to accomplish mobility related self-care tasks in the home. There is no 
indication they are unable to use an alternative assistive device. 
 
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 durable medical equipment (DME) have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861) and accessories (codes 
E2609, E1028, E1007, K0108, E0955, E1028, E2620, E0956, E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 18, 2022, billed with 
codes 87640, 87798, 87500, 87653, 87900, 87481, 87652, and 87899. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 18, 2022, billed with codes 87640, 87798, 87500, 87653, 87900, 87481, 87652, and 87899.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is able and willing to participate in an 
intensive rehabilitation program in hopes of maximizing function and reducing caregiver burden on their 
daughters. The Plan denied your request. The Plan says an IRF admission is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for February 17, 2023. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare requires that surgical pathology, including 
gross and microscopic examination, of any and all submitted prostate needle biopsy specimens from a single 
patient be reported with one unit of service of HCPCS code G0416 rather than CPT code 88305. 
 
We looked at the file and Medicare rules. The file shows that the services were billed with code 88305 and not 
required code G0416. 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 88305 billed 
for February 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service March 2, 
2023.  
 You asked the Plan to pay for procedure code 76642. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76642 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76642 billed for date of service March 2, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the DCISionRT IHC panel rendered on April 11, 2022. 
 
You asked the Plan to pay for the services. You say that this is needed to assist the provider in determining if 
radiation therapy is necessary. The Plan denied your request. The Plan says that the clinical value and 
effectiveness of the DCISionRT IHC panel to guide medical decision making for radiation therapy in the 
setting of ductal carcinoma in situ (DCIS) have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a history of DCIS, measuring 9mm ER/PR+. It is intermediate grade with necrosis, 
and the margins are all negative. The DCISionRT score performed showing elevated score. DCISion RT test 
has been validated in multiple independent studies including a randomized controlled trial where patients were 
treated with breast conservation surgery followed by randomization to radiation therapy and no radiation 
therapy. This test predicts radiation therapy benefit for females over the age of 30 with DCIS lesions smaller 
than 7 cm. The test was medically necessary and met the medical necessity criteria. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the DCISionRT IHC panel rendered on April 11, 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ambulance response without transport provided on April 
24, 2023. 
 
You asked the Plan to pay for an ambulance response without transport. You say that this should be covered 
because you could not go to the hospital to stabilize your blood sugar. The Plan denied your request. The Plan 
says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 24, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for an ambulance response without transport provided 
on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99204) 
rendered on March 9, 2023. 
 
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 Current Procedural Terminology (CPT) code 99204-95 (1 Unit) 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 99204 is "Office or other outpatient visit for the 
evaluation and management of a new patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 45-59 
minutes of total time is spent on the date of the encounter." 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the history and physical were 
medically appropriate. However, the plan included blood work, and GLP-1 medication for weight loss 
assistance. The documentation failed to support a moderate level of medical decision making, nor was there 
documentation supporting the duration of the encounter was 45-59 minutes as required for the 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for evaluation and management services (procedure code 99204) rendered on March 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 18, 
2023, through February 19, 2023. 
 
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 the acute inpatient hospital care provided was 
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. 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 these services. 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 enrollee with baseline dementia presented to the emergency department (ED) with  
seizure and a fall with a closed head injury discovered after evaluation. She was treated with Dilantin and 
Keppra. Her initial troponin level was elevated but the repeat evaluation indicated that the troponin level was 
normal. The enrollee was stable without new seizure activity. She was discharged home the day after 
presentation. Based on the stability of the enrollee, it was not expected that she would have required hospital 
care that would have likely crossed 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient hospital care provided from February 18, 2023, through February 19, 2023.