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

 
We decided that the Plan does not have to pre-approve cervical medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve the cervical MBBs. You say that this is medically necessary as other 
treatments have failed. The Plan denied your request. The Plan says there is not evidence of sufficient 
conservative treatment. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections and MBBs are covered when the 
criteria listed in the Medicare rules section of this decision are met.  
 
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 cervical MBBs. Our reviewer says 
that the requested MBBs are not considered medically necessary based on LCD criteria.  Our physician reviewer found the enrollee is a 74-year-old female with neck pain due to cervical spondylosis 
and radiculitis.  The onset of pain was noted to be on 1/1/2022.  Prior epidural steroid injection (ESI) was 
trialed.  Physical therapy (PT) trial noted 1/2022. Magnetic resonance imaging (MRI) showing foraminal 
stenosis and lower cervical segments.  He has been treated with medical therapy (NSAIDs).  Her provider has 
recommended bilateral C2-C3, C3-C4 MBBs. 
 
In this case, there is insufficient evidence of 3 months of conservative therapy and objective findings of facet 
arthropathy. The review has determined that the criteria for the requested cervical MBBs have not been met. 
 
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 cervical MBBs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve cervical medial branch blocks (MBBs).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing, 15-21 classes (G0482) provided on July 14, 
2021. 
 
You asked the Plan to pay for code G0482. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the billing of code G0482. 
 
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 G0482 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the record does not contain 
evidence that definitive testing on 15-21 drug classes was performed. Based on this information, we decided 
that Medicare rules for coverage of code G0482 have not been met. Therefore, we decided that the Plan does 
not have to pay for the drug testing, 15-21 classes (G0482) provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 15, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says despite 
multiple outreaches by the Health Plan, this provider has not submitted any clinical records to support the 
medical necessity of the service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
November 15, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical nasal/sinus endoscopy with dilation surgery 
for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not clearly indicate prior medical treatment; thus, the patient hasn't met 
standard medical therapy prior to procedure. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found at the visit dated 1/10/22, the patient reported facial discomfort and nasal congestion of indeterminate 
duration; nasal endoscopy showed no signs of infection. There was no clinical documentation of 
inflammation on subsequent nasal exam. The radiologist conclusion was that there was no evidence of sinusitis. 
At the 3/9/22 visit, the clinician reported that the CT scan showed narrowing of both frontal and sphenoid 
sinus but did not state whether this was attributable to inflammation, and there was no documented nasal exam 
other than diagnostic review.  The 2018 AAO-HNSF clinical consensus statement on balloon sinus dilation specifically noted consensus that 
objective evidence of inflammation on CT imaging was necessary in addition to sinonasal symptoms for a 
patient to be deemed appropriate to undergo balloon dilation of the sinuses. Given the available clinical 
documentation and peer-reviewed literature, the use of balloon-assisted endoscopic sinus surgery does not 
appear to be indicated for the patients symptoms. In summary, balloon-assisted endoscopic sinus surgery is not 
medically reasonable and necessary to manage the patients condition. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a surgical nasal/sinus endoscopy with dilation surgery for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two simple extractions (D7140 x2). 
 
You asked the Plan to pre-approve the extractions. You say that this dental work is required because of mouth 
cancer that you have. The Plan denied your request. The Plan says the requested service is not a covered benefit 
under your dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
simple extractions (D7140 x2).  
 
Please Note: Your dental coverage may have changed for the 2022 plan year. A new request could be 
submitted for the 2022 plan year under the new coverage.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 22, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says despite 
multiple outreaches by the Health Plan, this provider has not submitted any clinical records to support the 
medical necessity of the service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
November 22, 2021 have been met. The records provided to the Health Plan are undated, and unsigned. There 
is insufficient documentation of physical exam, pain scale, and response to prior injections. Therefore, we 
decided that the Plan does not have to pay for an epidural injection provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subarachnoid injection (code 62320) provided on 
December 20, 2021. 
 
You asked the Plan to pay for injection procedure. You say that Medicare covers this code with no diagnosis 
limitation. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the provider has not submitted the requires clinical records to support the necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that code 62320 is not covered by Medicare.  
 
We looked at the file and Medicare rules. You billed procedure code 62320 which is explicitly non-covered by 
Medicare. Based on this information, we decided that Medicare rules for coverage of injection procedure have 
not been met. Therefore, we decided that the Plan does not have to pay for a subarachnoid injection (code 
62320) provided on December 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 1, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says despite 
multiple outreaches by the Health Plan, this provider has not submitted any clinical records to support the 
medical necessity of the service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
November 1, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, 
per 30-minute interval (G0277) Physician attendance and supervision of hyperbaric oxygen therapy, per 
session (99183). 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that you are appealing because this 
treatment could benefit wound healing. The Plan denied your request. The Plan says the records do not support 
that the enrollee meets the requirements for approval. 
 
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 hyperbaric oxygen therapy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the review indicates that the enrollee does not have a wound due to 
diabetes which has failed 30 days of standard wound care, and no program payment may be made for HBOT 
used to treat cutaneous ulcers or chronic peripheral vascular insufficiency. The review has determined that the 
medical records provided do not meet the requirements listed in the NCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen under pressure, full body chamber, per 30-minute interval 
(G0277) Physician attendance and supervision of hyperbaric oxygen therapy, per session (99183).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 
11, 2021. 
 You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says only 16 drug classes were tested, per the laboratory results submitted. 
 
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 the denied codes is: 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument 
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
HCPCS G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found there is no documentation that support 
the above denied codes in this case. The records do not support that testing of 22 or more drug classes was 
performed on November 11, 2021.  
 
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 drug testing services provided to the enrollee on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by an opted-out physician on 
October 27, 2021. 
 
You asked the Plan to pay for office visit. You say that you are requesting reimbursement for this visit. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider 
opted out of the Medicare program and is not payable. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided by an opted-out physician on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided to the enrollee on 
November 15, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provider has not submitted the required clinical records to support the medical 
necessity of the service for the date of service requested on appeal. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found it appears that the provider is requesting coverage for additional intermittent subarachnoid injection of 
opioid medication through the existing implantable subarachnoid catheter. However, the clinical documentation 
does not support the purportedly performed procedure (CPT code 62320) on 11/15/2021. The provided 
documentation does not contain sufficient information in the medical records submitted.  In addition, the records submitted were not dated and not signed.  Therefore, the review has determined that the 
requested procedure was 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for pain management services provided to the enrollee on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided to the enrollee on 
November 8, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation must establish the medical necessity of these services. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found it appears that the provider is requesting coverage for additional intermittent subarachnoid injection of 
opioid medication through the existing implantable subarachnoid catheter.  However, the clinical 
documentation does not support the purportedly performed procedure (CPT code 62320) on 11/08/2021. The 
provided documentation does not contain sufficient information in the medical records submitted. In addition, 
the records submitted were not dated and not signed. Therefore, the review has determined that the requested procedure was 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for pain management services provided to the enrollee on November 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (CPT code(s): 35201, 31255-50, 31267-
50, and 31288-59-50) provided on June 2, 2021. 
 
You asked the Plan to pay for the surgical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 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 surgical services. Our reviewer found the services are not 
supported. Specifically, for CPT code 35201 - The general guidance for this code is that it is to be used for 
repair of a blood vessel in the neck. The Operative Note does not include documentation of repair of a blood 
vessel, direct.  
 
 For CPT code 31255-50 - The Operative Note does not include documentation of nasal/sinus endoscopy, 
surgical with ethmoidectomy; total (anterior and posterior) For CPT code 31288-50 - The Operative Note does 
not include documentation of sphenoidotomy with removal of tissue from the sphenoid sinus. 
 
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 surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services (CPT code(s): 35201, 31255-50, 31267-50, and 31288-59-50) 
provided on June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service February 
1, 2022. 
 You asked the Plan to pay for procedure code 70450-26. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496. 
 
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 70450 
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 procedure code 70450-26 billed for date of service February 1, 
2022.