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

 
We decided that the Plan does not have to pay for an emergency room visit billed with 99285 on October 24, 
2022. 
 
You asked the Plan to pay for an emergency room visit. You say that this was billed correctly. The Plan denied 
your request. The Plan says the records support code 99284, not 99285. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires a medically appropriate history and/or examination and high level 
of medical decision making. 
 
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 an emergency room visit. Our reviewer says that the billed 
code is not supported. Our reviewer found the submitted medical records do not support the level of medical 
decision making described by code 99285. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the 
Plan does not have to pay for an emergency room visit billed with 99285 on October 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Intracept procedure is experimental. More research is needed to demonstrate 
its safety and efficacy. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FoundationOne CDx (F1CDx) testing (0037U) 
 
You asked the Plan to pre-approve F1CDx testing. You say that this test is medically necessary. The Plan 
denied your request. The Plan says this test is not medically necessary, as the enrollee has previously had this 
test provided on May 7, 2021. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that NGS diagnostic laboratory tests may be considered medically 
necessary when the enrollee has not been previously tested with the same germline test using NGS for the same 
germline genetic content. 
 
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 F1CDx testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee previously had this same molecular testing done in 2021, and as this is a recurrence 
of the same tumor, this is a repeat test which is not 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 F1CDx testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve FoundationOne CDx (F1CDx) testing (0037U)
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 are in a wheelchair and cannot walk. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
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 clinical documentation does not specify any complex functional impairments or 
active medical comorbidities. Thus, the complexity of your nursing, medical, and rehabilitation needs would not be expected to 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 a pneumatic compression device (E0673, E0675) provided 
on August 11, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this service was medically 
necessary. The Plan denied your request. The Plan says these devices were used in the hospital setting and 
outside the home. 
 
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 a pneumatic compression device (E0673, E0675) provided on August 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. 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 therapeutic facet joint procedures are considered 
medically reasonable and necessary for patients who meet certain criteria. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve facet joint injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the medical record does not 
document 80% relief of pain from diagnostic facet joint injections or 50% relief from prior facet joint 
injections. In addition, there is no documentation of why the enrollee is not a candidate for radiofrequency 
ablation. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88342, 88112, 88305 and 83313 billed for 
date of service May 10, 2022. 
 
You asked the Plan to pay for procedure code(s) 88342, 88112, 88305 and 83313. 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 included in the facility payment and is not separately payable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88342, 88112, 88305 
and 83313. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88342, 
88112, 88305 and 83313. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88342, 88112, 88305 and 83313 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88342, 88112, 88305 and 83313 billed for date of service May 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the enrollee is 
medically stable, has no IV medication or complex wound care and currently at a high level of function. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis. 
 
You asked the Plan to pre-approve lumbar/sacral facet joint radiofrequency neurolysis. 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 diagnostic procedures should be performed with the 
intent that if successful, radiofrequency ablation (RFA) procedure would be considered the primary treatment 
goal at the diagnosed level(s). 
 
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 lumbar/sacral facet joint radiofrequency 
neurolysis. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
LCD requires 2 sets of diagnostic medial branch blocks (MBBs) before performing the RFA. Only one set has 
been performed. Therefore, at this point, 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 lumbar/sacral facet joint radiofrequency neurolysis have not been met. 
Therefore, we decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency 
neurolysis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presbyopia correcting (P-C) function of intraocular lens 
(IOL) (V2788) provided on September 21, 2022. 
 
You asked the Plan to pay for the P-C IOL. You say that you would like this appeal to be extended so that the 
doctor's notes reflect the medical necessity for the cataract surgery. The Plan denied your request. The Plan 
says Medicare does not cover presbyopia correcting intraocular lenses. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia correcting 
(P-C) function of intraocular lens (IOL) (V2788) provided on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia in the dental office or facility setting (code 00170) 
provided on November 2, 2022. 
 
You asked the Plan to pay for anesthesia. The Plan denied your request. The Plan says this service is not a 
covered benefit. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for anesthesia 
in the dental office or facility setting (code 00170) provided on November 2, 2022.
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. You say that due to your infection you need LTACH 
services. The Plan denied your request. The Plan says the request 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 you do not require services at the LTACH that are not available at the acute care 
hospital where you currently receiving care. All medically necessary care is being provided in the current acute 
care 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for crowns - porcelain/ceramic (D2740 x5), 
and resin-based composite - three surfaces, anterior (D2332) provided on October 18, 2022. 
 
You asked the Plan to waive the coinsurance for crown - porcelain/ceramic (D2740 x5), and resin-based 
composite - three surfaces, anterior (D2332). You say that you had four teeth filled and have a $2,000 a year 
benefit coverage. You also say that you have only used less than $500 with cleaning and x-rays. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. The Plan also says that the crowns - 
porcelain/ceramic (D2740 x5), and resin-based composite - three surfaces, anterior (D2332) were not covered 
because your benefit for these services had been exhausted. 
 
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. The rules say a plan must 
disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles 
and coinsurance). Your contract with the Plan clearly says that you must pay a $75% coinsurance for crowns, 
and a 55% coinsurance for resin-based composite (white)  anterior (front) or posterior (back) when provided 
out-of-network.   
 
You have been asked to pay a $75% coinsurance for crowns - porcelain/ceramic (D2740 x5). You have also 
been asked to pay a 55% coinsurance for the resin-based composite - three surfaces, anterior (D2332). These 
services were received from an out-of-network provider. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for crowns - porcelain/ceramic (D2740 x5), and additional resin-based composite - three surfaces, anterior 
(D2332) provided on October 18, 2022. 
 
The Plan contract says that 1 procedure code for a crown - porcelain/ceramic is covered per calendar year. The 
records shows that the Plan paid for a crown - porcelain/ceramic on October 18, 2022. This exhausted your 
benefit for the crown  porcelain/ceramic. The Plan contract also says that 2 procedure codes for resin-based 
composite are covered per calendar year. The record shows that the Plan paid for the resin-based composite on 
October 18, 2022. This exhausted your benefit for the resin-based composite. Therefore, we decided that the 
Plan does not have to waive the coinsurance for crowns - porcelain/ceramic (D2740 x5), and additional resin-
based composite - three surfaces, anterior (D2332) provided on October 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 27, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 
32555. 
 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 71045 
is a column II code to column I code 32555. 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 71045 billed for date of service March 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the thermal destruction of intraosseous basivertebral 
nerve (64628). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service 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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure is experimental for back pain. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the thermal destruction of intraosseous basivertebral nerve (64628).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that a SNF admission is medically necessary. The Plan 
denied your request. The Plan says SNF services requested are not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
However, the enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF 
setting. Required services can be provided in the home, in an assisted living facility with home health care, or 
in a long-term care facility on a part-time basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on 
August 12, 2022. 
 
You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical 
equipment have not been met. 
 
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 items at issue in this appeal were for use outside of the home. Although these items 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 pneumatic compression devices (E0675, E0673) provided on August 12, 2022.