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

 
We decided that the Plan does not have to pay for the regional abdominal lymphadenectomy and two unlisted 
laparoscopic liver procedures billed for date of service November 9, 2020, with codes 38747 and 47379 x2. 
 
You asked the Plan to pay for the services as billed. You say that this is billed correctly and should be paid. 
The Plan denied your request. The Plan says the codes at issue were not supported by the operative report. 
 
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 38747 is abdominal lymphadenectomy, regional, 
including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes (List 
separately in addition to code for primary procedure). The definition of code 47379 is Unlisted laparoscopic 
procedure, liver. 
 
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 as billed. Our reviewer says that the 
documentation does not support the reporting of the codes at issue in this case. Our reviewer found the 
operative report does not include documentation of removal of the celiac, gastric, portal, and peripancreatic 
lymph nodes. As such, code 38747 is not supported. The operative also does not describe an unlisted 
laparoscopic liver procedure. The procedure related to the liver in the operative report documents "We decided 
to perform a liver biopsy utilizing laparoscopic shears".  In this case, an unlisted procedure would not be 
reported for documentation, and in addition, 2 units cannot be verified.  When reporting an unlisted procedure 
code, documentation should describe the procedure being reported as an unlisted procedure. 
 
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 as billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the regional abdominal lymphadenectomy and two unlisted laparoscopic liver 
procedures billed for date of service November 9, 2020, with codes 38747 and 47379 x2.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this is considered experimental and 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The intracept 
procedure is experimental. More research is needed. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
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 the Intracept procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radiation therapy provided from 
January 2, 2020, to January 10, 2020. 
 
You asked the Plan to waive the copayment for the radiation therapy. You say that you have already paid your 
copays, and this is not acceptable. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $60 
copayment for therapeutic radiology.  
 
You have been asked to pay a $420 copayment for seven radiation therapy visits ($60 per visit x 7 visits = 
$420). Radiation therapy falls within the Outpatient Hospital Services benefit category. 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 copayment for the radiation therapy provided from January 2, 2020, to January 10, 
2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on June 2, 2021. 
 
You asked the Plan to pay for the x-ray.  The Plan denied your request. The Plan says original Medicare is 
responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an x-ray provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement grafts (D7953), guided tissue regeneration 
(D4266), sinus augmentation (D7951), and therapeutic parenteral drugs (D9610) provided on January 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says bone replacement grafts (D7953), guided tissue regeneration (D4266), 
sinus augmentation (D7951), and therapeutic parenteral drugs (D9610) are not covered by the enrollees routine 
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, 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 bone 
replacement grafts (D7953), guided tissue regeneration (D4266), sinus augmentation (D7951), and therapeutic 
parenteral drugs (D9610) provided on January 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on January 21, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. Based on this information, we decided that Medicare rules for coverage of the testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the FANCC genetic testing provided on 
January 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine 
(72148). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 this service. Our reviewer says that this 
service is not medically necessary. Our physician reviewer found that in this case, the record indicates that the 
enrollee has multilevel degenerative lumbar disease. Additionally, the record indicates that the enrollee is not 
currently being considered for operative intervention and will trial injections. The requested service is not 
medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this 
time. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular gene testing provided on 
November 1, 2021. 
 
You asked the Plan to pay for the testing services. You say that there are no other claims billed for the same 
date of service. The Plan denied your request. The Plan says the codes are included in a different code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that codes 81411, 81161, and 81238 are inclusive to code 81439. If a single procedure is performed, 
only one code with one unit of service may be reported for the procedure. Therefore, we decided that the Plan 
does not have to pay for the hereditary cardiovascular gene testing provided on November 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray provided on January 13, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for x-ray. You say that you are appealing the claim payment denial. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advanced. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the x-ray at issue in this appeal. The Plan did not pre-approve the x-ray at 
issue. We found no exception that would require the Plan to pay for the x-ray. Therefore, we decided that the 
Plan does not have to pay for x-ray provided on January 13, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the long-term acute 
care hospital (LTACH) services you are requesting do not meet the requirements for approval. 
 
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 patient appears to be more stable and should only require short-term additional 
acute care services that can safely be administered at the current facility until more appropriate for a lower level 
of care. The patient does not require services at the LTACH that are not already available at the current 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 21, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 lab services provided on January 21, 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) 
provided on April 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says they have already issued reimbursement for an 
emergency diagnostic exam. Reimbursement was previously issued for the date of service March 2, 2022. This means you will not receive a reimbursement for your claim cost. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 requested item or service was exhausted on date of service March 2, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and bitewing x-rays (D0274) provided on March 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you thought the provider was in-network. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110), and bitewing x-rays (D0274) 
provided on March 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on March 8, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic radiology services. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the diagnostic radiology services at issue in this appeal. The Plan did not 
pre-approve the diagnostic radiology services at issue. We found no exception that would require the Plan to 
pay for these diagnostic radiology services. Therefore, we decided that the Plan does not have to pay for 
diagnostic radiology services provided on March 8, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy provided from January 
11, 2022, to February 18, 2022. 
 
You asked the Plan to waive the copayment for the physical therapy. You say that you should not have been 
made to do physical therapy instead of just approving the shot. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
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 $20 
copayment for each visit.   
You have been asked to pay a $140 copayment for seven physical therapy visits ($20 per visit x 7 visits = 
$140). Physical therapy falls within the Outpatient Rehabilitation Services benefit category. 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 copayment for the physical therapy provided from January 11, 2022, to February 18, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) billed for February 4, 2022, 
to February 6, 2022. 
 
You asked the Plan to pay for critical care. You say that these services were billed appropriately. The Plan 
denied your request. The Plan says these services are not supported in the record as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing 
these services is not noted in the record for any of the dates in question. Without this information, a time-based 
code such as 99291 cannot be verified. Based on this information, we decided that Medicare rules for coverage 
of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, 
first hour (99291) billed for February 4, 2022, to February 6, 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. 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 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 based on the medical records provided there is no documentation that the 
enrollee requires the intensive medical care and the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. The medical records do not clarify that treatment at the skilled nursing facility 
level is not appropriate in this case. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nivolumab and cabozantinib. 
 
You asked the Plan to pre-approve nivolumab and cabozantinib. You say that the requested drugs are medically 
necessary. The Plan denied your request. The Plan says the use of this drug regimen is not reasonable and 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 nivolumab and cabozantinib. Our 
reviewer says that the criteria for coverage of nivolumab and cabozantinib have not been met. Our physician 
reviewer found these drugs are not FDA approved for use when there is progression on prior immunotherapy. 
The use of these drugs is not supported by one of the major drug compendia or by clinical research that appears 
in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nivolumab and cabozantinib have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nivolumab and cabozantinib.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
February 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. 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 items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The Plan verified with the ordering provider's office and verified that 
there is no written order on or before this date of service. Based on this information, we decided that Medicare 
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided February 28, 2022.