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

 
We decided that the Plan does not have to pay for the Afirma assay rendered on November 3, 2022.  
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says documentation of characteristics concerning for malignancy were not in the records. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer 
found that the medical records that were reviewed do not demonstrate any of the following which are required 
for coverage: nodule growth over time, family history of thyroid cancer, hoarseness, difficulty swallowing or 
breathing, history of exposure to ionizing radiation, hard nodule compared with rest of gland consistency, 
presence of cervical adenopathy. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for the Afirma assay rendered on November 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 
20, 2022.  
 You asked the Plan to pay for procedure code 76641. You say that this should be paid for. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service December 20, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET scan with CT scan. 
 
You asked the Plan to pre-approve a PET scan with CT scan. You say that the enrollee has cancer and needs a 
PET scan immediately as their condition is life threatening. The Plan denied your request. The Plan says that a 
PET scan with CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET scan with CT scan. Our reviewer 
says that a PET scan with CT scan is medically necessary. Our physician reviewer found that the enrollee has 
significant chronic renal disease and is not a candidate for iodinated contrast which would be necessary for CT 
scans.  Given the monoclonal gammopathy and possible occult malignancy and based upon history and 
presentation the request for PET scan with CT scan which can be done without nephrotoxicity to look for 
occult malignancy including multiple myeloma is reasonable and should be approved. 
 
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 PET scan with CT scan have not been met. Therefore, we decided that the 
Plan has to pre-approve a PET scan with CT scan.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 provided on September 15, 2022. 
 
You asked the Plan to pay for procedure code 99284. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on October 21, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 99284 have not been met.  Therefore, we decided that the Plan does not have to pay for procedure code 99284 provided on September 15, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of bone joints between wrists and fingers. 
 
You asked the Plan to pre-approve removal of bone joints between wrists and fingers. You say that you have 
arthritis and trigger finger, and your doctor did not recommend physical therapy because you are not able move 
your wrist. You say that you are in a lot of pain and need the relief this surgery can provide. The Plan denied 
your request. The Plan says the requested surgery to remove bone joints between wrists and fingers 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 removal of bone joints between wrists 
and fingers. Our reviewer says that the requested removal of bone joints between wrists and fingers is not 
considered medically reasonable and necessary in this case. Our physician reviewer found you are being treated for left thumb CMC (carpometacarpal) arthritis and trigger thumb. You have declined cortisone injections and 
you are ready to discuss surgery. The exam reveals marked pain at the CMC joint with a positive CMC grind 
test for crepitus and pain. You have tenderness to palpation volar at the level of the first annular (A1) pulley 
where there is a small palpable nodule and clicking with passive extension of the thumb in flexion. X-rays are 
noted to show CMC arthritis with joint space narrowing, osteophyte formation, and subchondral sclerosis.  
However, detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. There are limited large-scale, long-term references showing 
the safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested removal of bone joints between her wrists and fingers, 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 removal of bone joints between wrists and fingers have not been met. 
Therefore, we decided that the Plan does not have to pre-approve removal of bone joints between wrists and 
fingers.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023 to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this should be paid for. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023 to January 28, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
December 24, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is not enrolled in Medicare and is not 
eligible to bill Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on December 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service January 5, 
2023.  
 
You asked the Plan to pay for procedure code 99291. You say that this should bge paid for. 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 99291 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 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous lumbar decompression procedure 
(0275T). 
 
You asked the Plan to pre-approve a percutaneous lumbar decompression. You say that the requested 
procedure is a necessity for your care. The Plan denied your request. The Plan says rules for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when 
provided in a clinical study. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a percutaneous lumbar decompression have not been met. Specifically, there is no evidence in the 
case record that you are participating in an approved study. Therefore, we decided that the Plan does not have 
to pre-approve a percutaneous lumbar decompression procedure (0275T).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 the records show that you have not 
tried and failed the Plan's required drugs, Dysport and Xeomin. The records do not show that the required drugs 
would be less effective or have adverse effects; therefore, Botox is 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 pre-approve Botox.
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 inpatient rehabilitation is the best next level of care 
for stroke and neurological disorder for the enrollee. The Plan denied your request. The Plan says the enrollee's 
records show that it is not reasonable to expect that you will be able to safely participate in, or fully benefit 
from, the intensity of services of an IRF. 
 
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 an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system (A4305) provided on 
January 1, 2022, to January 3, 2022. 
 
You asked the Plan to pay for the disposable drug delivery system. You say that you would like this claim to be 
processed. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the disposable drug delivery system have not been met. Therefore, we decided that the Plan does 
not have to pay for the disposable drug delivery system (A4305) provided on January 1, 2022, to January 3, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you have cerebral palsy, and you 
would benefit from a fully electric bed with full positioning. The Plan denied your request. The Plan says the 
requested bed is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes G0463, J3420 and 96372 for date of service December 
1, 2022. 
 
You asked the Plan to pay for codes G0463, J3420 and 96372. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT codes G0463, J3420 and 96372 are not supported in the medical record. Specifically, these 
codes were billed with a principal diagnosis code Z79.890 Hormone replacement therapy, is identified to be 
unacceptable as principal diagnosis in the Medicare Code Editor. This means the claim is not payable as billed.  
 
 Based on this information, we decided that Medicare rules for coverage of codes G0463, J3420 and 96372 have 
not been met. Therefore, we decided that the Plan does not have to pay for codes G0463, J3420 and 96372 for 
date of service December 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service January 12, 
2023.  
 You asked the Plan to pay for procedure code 76641. You say that this should be paid for. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service January 12, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service December 
14, 2022. 
 You asked the Plan to pay for procedure code 70544. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70544 is bundled into payment for code 70551. 
 
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 70544 
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 70544 billed for date of service December 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hepatitis A and Hepatitis B vaccine (HepA-HepB) 
(90636), and administration (90472) provided on October 4, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that the services should be covered. The Plan 
denied your request. The Plan says the vaccine services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine services. Therefore, we decided that the Plan does not have to pay for the Hepatitis A and Hepatitis B vaccine 
(HepA-HepB) (90636), and administration (90472) provided on October 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided on October 10, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that this device was 
provided for use during the patient's surgery. The Plan denied your request. The Plan says equipment used in a 
facility for a procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) 
provided on October 10, 2022.
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. The Plan denied your request. The Plan says the enrollee does not 
meet the guidelines for services in an Inpatient Rehab Facility. 
 
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 an interdisciplinary approach to rehabilitation 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.