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

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on June 8, 2023, and billed with codes 87900, 87799, 87798, 87652, 87640, 87500, and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary.  The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing provided on June 8, 2023, and billed with codes 87900, 87799, 87798, 87652, 87640, 87500, and 
87481.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27335 rendered on April 28, 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 the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 27335 is "Arthrotomy, with synovectomy, knee; anterior 
AND posterior including popliteal area." 
 
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 procedure details cite there 
was significant synovitis so a synovectomy was performed at the suprapatellar pouch and medial and lateral gutters. The specimens were sent for cultures. The tibial poly was removed as well as the synovium from the 
back of the knee. The synovectomy was performed overall in part of the revision of the right knee. Therefore, 
the documentation does not support CPT 27335: arthrotomy with synovectomy, knee, anterior AND posterior 
including popliteal area as a separate and distinct procedure from CPT 27486: revision of total knee 
arthroplasty, with or without allograft, 1 component. 
 
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 code 27335 rendered on April 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 44160-22 billed for date of service August 6, 
2022. 
 
You asked the Plan to pay for procedure code 44160-22. You say that this service was necessary and was 
reported appropriately. The Plan denied your request. The Plan says this code is not supported with the -22 
modifier as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the definition of modifier -22 is increased procedural services: when the work required to provide a 
service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual 
procedure code. Documentation must support the substantial additional work and the reason for the additional 
work (i.e., increased intensity, time, technical difficulty of procedure and severity of patient's condition, 
physical and mental effort required). 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 procedure code 44160-22. Our reviewer says that this service 
is not supported with the reported modifier. Our reviewer found that in order to use modifier 22 effectively, the 
surgical documentation must include a description of why the care was especially difficult and the extenuating 
circumstances encountered intraoperatively that set this procedure apart from the standard expectation of 
complexity. The procedure report or supporting documentation was not included, and therefore 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 procedure code 44160-22 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 44160-22 billed for date of service August 6, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oncogenomic Heme v (81479). 
 
You asked the Plan to pre-approve Oncogenomic Heme v. 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 genetic testing 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 Oncogenomic Heme v. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found based on the diagnostic 
program, MolDX Technical Assessment, the requested test is not an approved test per review of the MolDX 
Program website. The review has determined that the enrollee does not meet the coverage criteria detailed in 
the LCD and NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Oncogenomic Heme v have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Oncogenomic Heme v (81479).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on March 13, 2023, billed with 
procedure codes Q0092 (x2), R0070, 76770 and 76856. 
 
You asked the Plan to pay for the testing services provided. You say that that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes Q0092 (x2), R0070, 76770 and 76856 is set-up portable 
x-ray equipment, transportation of portable x-ray equipment and personnel to home or nursing home, per trip to 
facility or location, one patient seen, ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image 
documentation; complete, and ultrasound, pelvic (nonobstetric), real time with image documentation; complete. 
 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 testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the documentation does not include 
sufficient documentation to verify the billed codes. 
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on March 13, 2023, billed with procedure codes Q0092 
(x2), R0070, 76770 and 76856.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging tomographic. 
 
You asked the Plan to pre-approve myocardial perfusion imaging tomographic. You say that myocardial 
perfusion imaging tomographic is medically necessary. The Plan denied your request. The Plan says 
myocardial perfusion imaging tomographic 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 myocardial perfusion imaging 
tomographic. Our reviewer says that the requested myocardial perfusion imaging tomographic is not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the patient has 
no chest pain or shortness of breath. There is no documentation that the electrocardiogram (ECG) shows an 
uninterpretable pattern. There is no evidence provided that would support the need for radionuclide stress testing. In summary, there is insufficient documentation to support the medical necessity for the requested 
cardiac stress testing in this patients 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 myocardial perfusion imaging tomographic have not been met. Therefore, we 
decided that the Plan does not have to pre-approve myocardial perfusion imaging tomographic.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says  an 
LTACH admission is not medically necessary.  
 
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 that the enrollee's needs are met in the current setting and an LTACH does not 
provide any services that the enrollee is not already receiving. 
 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers 48 one-way transportation trips when each one-way trip does not exceed 50 miles. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage.
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 requires this care for 
recovery. The Plan denied your request. The Plan says the enrollee's care can be provided at the current facility 
until they are more stable for transfer to another level of care.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve physical therapy services with an out-of-network provider. You say that you 
want the Plan to approve the services. The Plan denied your request. The Plan says the provider is out-of-
network. The requested services are available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
   
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.
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 you would like reconsideration of the denied 
authorization. The Plan denied your request. The Plan says the rules for IRF care have not been met. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with interdisciplinary approach to rehabilitation care. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation program. 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 81456 billed for date of service April 14, 
2023.  
 
You asked the Plan to pay for procedure code 81456. 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 II code to column I code 81455 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 81456 
billed for date of service April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the TenJet procedure. 
 
You asked the Plan to pre-approve the TenJet procedure. You say that you have complex pain syndrome that is 
called "suicide disease", and you have complex neuropathy. The Plan denied your request. The Plan says the 
TenJet procedure is a newer procedure that has undergone a few small clinical trials. The TenJet procedure is 
considered experimental, and more investigation or clinical studies are needed to evaluate its effectiveness. In 
addition, TenJet has not been shown to improve outcomes compared to standard methods of treatment. 
Currently, the TenJet is not recommended in the current guidelines for the treatment of joint pain or tendon 
problems. 
 
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 TenJet procedure. Our reviewer says that the requested TenJet procedure is not considered medically reasonable and necessary. Our physician 
reviewer found that you have both knee and ankle pain, and you have tried and failed oral medications. You 
have had neurolysis of your nerves about the ankle and you have had prior TenJet procedures on your knees. 
The TenJet procedure is considered experimental, and additional clinical studies are needed to evaluate its 
effectiveness. Currently, the TenJet is not recommended in the current guidelines for the treatment of joint pain 
or tendon problems. Therefore, 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 the TenJet procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the TenJet procedure.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 18, 2022, to 
October 17, 2022. 
 You asked the Plan to pay for the home health services. You say that there is a NOA on file. The Plan denied 
your request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is February 20, 2022. The NOA was not received by the Plan until January 
11, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 18, 2022, to October 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45378 billed for date of service April 5, 
2023. 
 
You asked the Plan to pay for procedure code 45378. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this code is not supported as 
billed and would be more accurately reported with modifier -52 appended. 
 
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 45378 is colonoscopy, flexible; diagnostic, including 
collection of specimen(s) by brushing or washing, when performed (separate procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure code 45378. Our reviewer says that this code is not supported as reported. Our reviewer found that the procedure report documents, "The Colonscope was 
introduced through the anus and advanced to the ascending colon for evaluation. This was the intended extent". 
In this case, procedure code would require an appropriate modifier, as procedure code criteria was not 
supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 45378 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 45378 billed for date of service April 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 5, 2023, to 
March 6, 2023. 
 You asked the Plan to pay for the home health services. You say that previous claims were paid, so this one 
should be paid too. The Plan denied your request. The Plan says the NOA was not received timely. As such, 
this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 6, 2023. The NOA was not received by the Plan until March 30, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from February 5, 2023, to March 6, 2023.