Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Introduction/Injection of Anesthetic Agent (Nerve 
Block), Diagnostic or Therapeutic Procedures on the Paravertebral Spinal Nerves and Branches--lumbar facet 
joint injections (64494). 
 
You asked the Plan to pre-approve Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or 
Therapeutic Procedures on the Paravertebral Spinal Nerves and Branches--lumbar facet joint injections. The 
Plan denied your request. The Plan says the member does not have at least 80% reduction in her pain from the 
prior injection diagnostic injections or greater than 50% relief for at least three months for a previous 
therapeutic injection. 
 
The Plan follows Medicare rules.  
 
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 Introduction/Injection of Anesthetic 
Agent (Nerve Block), Diagnostic or Therapeutic Procedures on the Paravertebral Spinal Nerves and Branches--lumbar facet joint injections. Our reviewer says that the requested diagnostic facet joint procedure is not 
medically necessary. Our physician reviewer found in this case, the first injection did not produce 80% or 
greater pain relief and the duration of relief was not consistent with the agents used. The review has determined 
that the requested injections do not meet the coverage 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 Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or 
Therapeutic Procedures on the Paravertebral Spinal Nerves and Branches--lumbar facet joint injections have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Introduction/Injection of 
Anesthetic Agent (Nerve Block), Diagnostic or Therapeutic Procedures on the Paravertebral Spinal Nerves and 
Branches--lumbar facet joint injections (64494).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310), occlusion analysis (D9950), 
extractions (D7210 x 4), unspecified adjunctive procedure (D9999), and 3 retainer crowns (D6750) provided 
from March 3, 2021, to November 1, 2021, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. You say 
that you believe the dental infections raised your PSA level. You also say that the services should be paid in 
full. The Plan denied your request. The Plan says the dental services you received are not listed as covered. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the consultation, occlusion analysis, 
extractions, unspecified adjunctive procedure, and retainer crowns are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310), occlusion 
analysis (D9950), extractions (D7210 x 4), unspecified adjunctive procedure (D9999), and 3 retainer crowns 
(D6750) provided from March 3, 2021, to November 1, 2021, by the out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular radiofrequency ablation. The Plan denied your request. The Plan 
says genicular radiofrequency ablation 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 genicular radiofrequency ablation. Our 
reviewer says that genicular radiofrequency ablation is not medically reasonable or necessary. Our physician 
reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee 
replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested genicular nerve 
radiofrequency ablation 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 genicular radiofrequency ablation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the introduction of needle or intracatheter (36000) provided 
on August 28, 2021. 
 
You asked the Plan to pay for the introduction of needle or intracatheter (36000). You say that the patient went 
to the emergency room and was seen by the emergency room physician for a medically necessary procedure. 
You say that the claim should be reprocessed to pay this procedure code. The Plan denied your request. The 
Plan says bundled services are not eligible for separate payment.  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 code 36000 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 36000 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the introduction of needle or intracatheter (36000) have not been met. Therefore, we decided that the Plan 
does not have to pay for the introduction of needle or intracatheter (36000) provided on August 28, 2021.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on April 24, 2022 with weakness and abdominal pain. She is now medically stable with no complex 
nursing or rehabilitation needs. She does not require supervision by a physical medicine and rehabilitation physician three times per week (at a minimum) for the ongoing management of any active or acute 
exacerbations of chronic medical conditions. She has skilled therapy needs but does not require the intensive 
therapy program in an IRF. The complexity of the enrollee's nursing, medical and rehabilitation needs do 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261) provided on September 30, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aid. You say that you were not aware that the treating provider was 
OON. The Plan denied your request. The Plan says hearing aids must be purchased through the Plan's hearing 
aid vendor to be covered under the hearing aid services offered by your plan. The Plan also says that you had 
no OON coverage for hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plan's hearing aid vendor.  
 
 
 
 
 
 
  
 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the 
hearing aid (V5261) provided on September 30, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261) and hearing aid dispensing fee 
(V5110) provided on December 17, 2021 by an out-of-network provider. 
 
You asked the Plan to pay for the hearing aid and hearing aid dispensing fee. You say that when you purchased 
your plan you were told that $699 would be paid for hearing aids. The Plan denied your request. The Plan says 
the treating facility is not in-network with the Plan's hearing aid vendor. The Plan also says that the Plan's 
hearing aid vendor does not offer reimbursement for hearing aids purchased out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when you use the Plans hearing aid vendor for hearing aid services.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid and hearing aid dispensing fee have not been met. Therefore, we decided that the 
Plan does not have to pay for the hearing aid (V5261) and hearing aid dispensing fee (V5110) provided on 
December 17, 2021 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2755, V2100, V2760, V2020) purchased on 
December 16, 2021. 
 You asked the Plan to pay for the eyeglasses. You say that the provider told you to pick another pair of 
eyeglasses; you did not ask for two pairs. The Plan denied your request. The Plan says you purchased two pairs 
of eyeglasses on the date in question. The first pair has been paid in full; however, the second pair exceeds your 
benefit limitation of one per calendar year and remains denied. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglasses and pair of lenses or contact lenses per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that you purchased two pairs of eyeglasses on the 
date in question, and one of these pairs was covered by the Plan. Based on this information, we decided that the 
Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not 
have to pay for the eyeglasses (V2755, V2100, V2760, V2020) purchased on December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays rendered on September 24, 2021. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 x-rays rendered on 
September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vascular surgeon consultation to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve vascular surgeon consultation. You say that this care is medically necessary. 
The Plan denied your request. The Plan says there are in-network providers available to provide the requested 
medical care. 
 
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 
vascular surgeon consultation to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346), comprehensive oral evaluation (D0150), and complete series of intraoral x-
rays (D0210) provided on October 14, 2021, and October 27, 2021. 
 
You asked the Plan to pay for the scaling, comprehensive oral evaluation, and complete series of intraoral x-
rays. You say that you had to change dental offices to get your teeth cleaned. The Plan denied your request. 
The Plan says the scaling is not a covered benefit under your dental plan. The Plan says that the comprehensive 
oral evaluation and complete series of intraoral x-rays exceed the frequency limitations in your benefit plan. 
The Plan also says that no calls were made by you to the Plan's customer service prior to these dates of service 
requesting dental plan benefits, limitations, or cost share assessment.  
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, scaling in presence of generalized 
moderate or severe gingival inflammation (D4346) is not among those covered under this benefit. The contract 
says that comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each 
limited to one procedure every three plan years. The record shows that you received a comprehensive oral 
evaluation (D0150) and complete series of intraoral x-rays (D0210) on January 22, 2020 and your 
comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been 
exhausted. Therefore, we decided that the Plan does not have to pay for the scaling in presence of generalized 
moderate or severe gingival inflammation (D4346), comprehensive oral evaluation (D0150), and complete 
series of intraoral x-rays (D0210) provided on October 14, 2021, and October 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70470) provided on November 30, 2021. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that you have provided records to 
support the level of service. The Plan denied your request. The Plan says rules for payment have not been met 
because the code at issue is inclusive to another billed code. 
 
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 70470 
is a column II code to column I code 70496. 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 a computed tomography (CT) scan of the head or brain (70470) 
provided on November 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on December 17, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that according 
to plan operations ambulances are covered. You also say that if the Plan were to check your 2021 record, it 
shows that the Plan paid for ambulance service in the past. The Plan denied your request. The Plan says since 
there was no transport, the ambulance charges are 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 December 17, 2021. 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 the ambulance response and treatment with no 
transport (A0998) provided on December 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pharmacogenetic testing coded with 81240, 
81241, 81220, 81227, 81230, 81291, 81335, 81355 provided September 17, 2021. 
 
You asked the Plan to pay for the molecular pharmacogenetic testing. You say that you provided medically 
necessary services in good faith. The Plan denied your request. The Plan says does not meet Medicare 
NCD/LCD criteria. 
 
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 find that CPT codes 81240, 81241, 81220, 81227, 81230, 81291, 81335, 81355 is not 
supported in the medical record. Specifically, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel 
constitutes a single procedural service, so one CPT code must be submitted for the panel. Based on this 
information, we decided that Medicare rules for coverage of the molecular pharmacogenetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the molecular pharmacogenetic testing 
coded with 81240, 81241, 81220, 81227, 81230, 81291, 81335, 81355 provided September 17, 2021.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that this care is medically necessary. The Plan 
denied your request. The Plan says there are in-network providers available. 
 
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 
an office visit (99214) 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 inpatient psychiatric treatment. 
 
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 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 treatment. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review of the records provided you do not meet criteria for acute inpatient mental health treatment as you were not 
shown to be a danger to yourself or others. You were not experiencing auditory or visual hallucinations. You 
are noted to be cooperative and compliant with treatment while not showing any acute threat to safety. 
 
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 treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric treatment.