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

 
We decided that the Plan does not have to pre-approve a destruction by neurolytic agent, genicular nerve 
branches including imaging guidance (64624x 2 units). 
 
You asked the Plan to pre-approve genicular radiofrequency ablation (RFA). You say that the enrollee needs 
this procedure to complete the required next step of the surgical process. He needs it to function and/or walk. 
The Plan denied your request. The Plan says RFA is a treatment using heat and sounds waves to help with 
longstanding knee pain. There is not enough medical proof that shows the safety and/or success of this 
treatment so it is considered experimental and/or unproven. 
 
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 
(RFA). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a history of bilateral knee pain due to 
osteoarthritis. His pain is rated 6/10, which is made worse by standing and walking. He has been treated with 
medications and underwent diagnostic bilateral genicular blocks on March 13, 2023, which provided 95-100% 
pain relief for 4-5 hours. 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 
radiofrequency ablations are 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 (RFA) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a destruction by neurolytic agent, genicular nerve branches 
including imaging guidance (64624x 2 units).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 19, 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 claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 laboratory services rendered on 
October 19, 2021.
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 you are requesting reconsideration for 
the denial of an LTACH admission. The Plan denied your request. The Plan says you do not meet the 
guidelines for care in an LTACH. 
 
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 the acute hospital can provide for all your present inpatient care needs. You are 
receiving an appropriate level of care in the present setting, and the Plan has not stated that continued care in 
the short-term acute hospital will not be covered. Continued care in the short-term acute hospital is appropriate 
until you are stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute 
rehabilitation facility or a skilled nursing facility. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99220) provided on September 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99220 is "Initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit". 
 
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 use of code 99220 is not supported by the records provided. Our reviewer found that the medical records submitted do not support 
medical decision making of high complexity. 
 
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 the services (99220) provided on September 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the Invisalign (D8680) provided on April 29, 
2022. 
 
You asked the Plan to reimburse you for the Invisalign. You say that this treatment was for a medical reason 
resulting from accidental injury. The Plan denied your request. The Plan says orthodontic care is not covered 
by Medicare or the Plan. 
 
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 Invisalign is not among those 
covered under this benefit. Additionally, the orthodontic service you are asking the Plan to reimburse you for 
involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting 
your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that 
the Plan does not have to reimburse you for the Invisalign (D8680) provided on April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDX DiffDx Melanoma testing (0314U) provided on 
August 11, 2022. 
 
You asked the Plan to pay for DecisionDX DiffDx Melanoma testing. You say that this test was medically 
necessary and is clinically validated. The Plan denied your request. The Plan says this test is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that Medicare rules for coverage of DecisionDX DiffDx Melanoma testing have not been met. Therefore, we 
decided that the Plan does not have to pay for DecisionDX DiffDx Melanoma testing (0314U) provided on 
August 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96372 billed for date of service October 5, 
2022. 
 
You asked the Plan to pay for procedure code 96372. You say that you have submitted medical records to 
support payment. The Plan denied your request. The Plan says payment for code 96372 is bundled into 
payment for code 96365. 
 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 96372 
is a column II code to column I code 96365. 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 96372 billed for date of service October 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
interim partial denture (D5820) provided on October 17, 2022, to October 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you reached out to the dentist for emergency 
weekend hours but there was no response. You also say that the Plan stated the emergency dentist was in-
network. The Plan denied your request. The Plan says your benefit for the limited oral evaluation - problem 
focused (D0140) has already been exhausted, and the interim partial denture (D5820) is not covered under the 
Plans dental benefits. 
 
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, certain limitations apply. The record 
shows your benefit for the limited oral evaluation - problem focused (D0140) was exhausted on date of service 
February 7, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - 
problem focused (D0140), and interim partial denture (D5820) provided on October 17, 2022, to October 19, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99223, 99232, 99497) provided on July 25, 
2022, and July 27, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit". 
 
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 use of codes 99223, 
99232, and 99497, is not supported by the records provided. Our reviewer found that for code 99223, the 
medical records submitted do not support medical decision making of high complexity. For code 99232, the 
documentation submitted does not include a subsequent hospital care evaluation and management note for the 
billed date of service. Therefore, the billed service cannot be verified. For code 99497, the documentation 
submitted does not indicate that advance care planning was performed for the billed date of service. Therefore, 
the billed service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (99223, 99232, 99497) provided on July 25, 2022, and July 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99204, 74230, 72040, 70100, 70310, 71045, 
and 74240, provided on November 17, 2022. 
 
You asked the Plan to pay for an office visit, an imaging for evaluation of swallowing function, an x-ray of part 
of lower jaw, an x-ray of teeth, an x-ray of chest, and an x-ray of upper gastrointestinal tract with barium. You 
say that the claim was billed correctly and should be paid. The Plan denied your request. The Plan says the 
services were billed with the wrong place of service code. 
 
The rules say that for mobile units serving an entity with its own POS code, the entity's POS code should be 
reported. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit, imaging for evaluation of swallowing function, x-ray of part of lower jaw, x-ray of 
teeth, x-ray of chest, and x-ray of upper gastrointestinal tract with barium have not been met. The documentation supports that the enrollee was at a skilled nursing facility on the date of service. As such, the 
use of the mobile POS code is not appropriate. Therefore, we decided that the Plan does not have to pay for 
procedure codes 99204, 74230, 72040, 70100, 70310, 71045, and 74240, provided on November 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular diagnostic testing provided on September 23, 
2022. 
 
You asked the Plan to pay for molecular diagnostic tests. You say that this is a Medicare-covered benefit. The 
Plan denied your request. The Plan says this testing was not billed with the correct coding. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a molecular diagnostic test, submit the 
appropriate procedure code, 1 unit of service, and the appropriate DEX Z-Code identifier.  
 
We looked at the file and Medicare rules. This claim was not billed with the appropriate DEX Z-Code 
identifier. Based on this information, we decided that Medicare rules for coverage of molecular diagnostic tests 
have not been met. Therefore, we decided that the Plan does not have to pay for molecular diagnostic testing 
provided on September 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99212) provided on May 31, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is not separately payable. 
 
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 99212 is not supported in the medical record. Specifically, code 99212 is included in 
the global surgery package of code 36482 which was also billed. Based on this information, we decided that 
Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99212) provided on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on October 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these tests are included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on October 
5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA test provided on November 16, 2022. 
 
You asked the Plan to pay for the PrismRA test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the PrismRA test have not been met. 
Therefore, we decided that the Plan does not have to pay for the PrismRA test provided on November 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4595 billed for September 28, 2022. 
 
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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure code A4595 billed for September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the hip orthosis (L1686), and pelvic control, hip joint range of motion 
(ROM) (L2624) provided on July 8, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the item was medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the documentation submitted did not sufficiently support the billed 
supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid physician order and proof of delivery for the supplies provided in this case. 
Therefore, we decided that the Plan has to pay for the hip orthosis (L1686), and pelvic control, hip joint range 
of motion (ROM) (L2624) provided on July 8, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy. 
 
You asked the Plan to pre-approve bioimpedance spectroscopy. The Plan denied your request. The Plan says 
that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve bioimpedance spectroscopy. Our 
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that traditional diagnostic modalities are less able to detect reversible subclinical 
breast cancer-related lymphedema (BCRL), while newer techniques such as bioimpedance spectroscopy (BIS) 
have shown the ability to detect subclinical BCRL, allowing for early intervention and low rates of chronic 
BCRL with level I evidence. This enrollee had an axillary node dissection with the removal of 17 nodes. She is 
at high risk of lymphedema. The use of BIS is 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 bioimpedance spectroscopy have been met. Therefore, we decided that the Plan 
has to pre-approve bioimpedance spectroscopy.  
 
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.