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

 
We decided that the Plan does not have to pay for the anesthesia services (CPT code 99152) provided on 
December 31, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the documentation submitted did not indicate the presence of an independent 
trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; 
therefore, the billed service cannot be verified. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
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 anesthesia services. Our reviewer found the 
documentation submitted did not indicate the presence of an independent trained observer to assisting the 
monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot 
be verified. Of note, an independent trained observer is someone other than the physician performing the 
services. The review has determined that the service is not supported in the medical records provided. 
 
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 anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services (CPT code 99152) provided on December 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and mandibular 
partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests 
and teeth) (D5214) provided January 17, 2022. 
 
You asked the Plan to pay for the complete upper denture and lower partial denture. You say that you feel these 
services should be covered. The Plan denied your request. The Plan says these services are not covered under 
your 2022 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. Although it appears that you received a pre-approval for the services in 2021, this authorization appears to have been issued by a different plan. Therefore, we decided that the Plan 
does not have to pay for the complete denture - maxillary (D5110) and mandibular partial denture - cast metal 
framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided 
January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750). 
 
You asked the Plan to pre-approve the crown. You say that the crown is medically necessary. The Plan denied 
your request. The Plan says this 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 pre-approve a 
crown (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy (D3410) and a retrograde filling (D3430), 
provided by an out-of-network provider on January 13, 2022. 
 
You asked the Plan to pay for an apicoectomy and a retrograde filling. You say that you have an abscess, and 
you needed these services. The Plan denied your request. The Plan says the rendered dental services are not 
covered. 
 
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, 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 an 
apicoectomy (D3410) and a retrograde filling (D3430), provided by an out-of-network provider on January 13, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from August 11, 2021, through 
August 17, 2021. 
 
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the SNF benefit 
period has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from July 20, 2021, 
though January 21, 2022. The Plan has covered 100 days of SNF care.  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for SNF services provided from August 11, 2021, through August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a removal of torus mandibularis procedure (D7473). 
 
You asked the Plan to pre-approve a removal of torus mandibularis. You say that the requested service is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for dental services 
have not been met. 
 
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 a 
removal of torus mandibularis procedure (D7473).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says medical studies have not proven that the service(s) or procedure(s) 
is helpful for treatment of the enrollee's health problem. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation is not evident regarding a specific indication provided to 
support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-
term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollees medical 
condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested bone marrow aspirate in the setting of a fusion, in this case, is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing (CPT 
code(s): 81404-90-XS x 2, and 81479-90-GY x 2) provided on May 11, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening testing. You say that the claim 
should be paid. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the cardiac risk assessment genetic screening testing, was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. The documentation does 
not indicate how the test results will assist in managing the member's condition. Therefore, the denial of the 
cardiovascular screening/risk assessment panel is administratively upheld for not meeting Medicare coverage 
criteria. Therefore, we decided that the Plan does not have to pay for cardiac risk assessment genetic screening 
testing (CPT code(s): 81404-90-XS x 2, and 81479-90-GY x 2) provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the resin-based composite - two 
surfaces, posterior (D2392) and resin-based composite - three surfaces, posterior (D2393) provided February 
22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the fillings. You say that you feel the balance should be 
covered. The Plan denied your request. The Plan says the claim was processed correctly according to your 
OON 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 Plan covers the fillings up 
to a $500 benefit maximum per calendar year.  
We looked at the file and Medicare rules. At the time the services were provided you had $252 remaining in 
your dental benefit maximum. This amount was applied to the filling  two surfaces (D2392). You have been 
asked to pay the remaining amount ($5) for this filling plus the cost of the second filling ($329). This means 
you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided 
that the Plan does not have to provide additional payment for the resin-based composite - two surfaces, 
posterior (D2392) and resin-based composite - three surfaces, posterior (D2393) provided February 22, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction provided on January 14, 2022. 
 
You asked the Plan to pay for the extraction. You say that the Plan assigned you this dentist due to a dental 
emergency. You say that it was verified they were part of the network at the time of service and these charges 
will be a hardship. The Plan denied your request. The Plan says services obtained from vendors outside the 
network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction provided on January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right occipital nerve radiofrequency ablation.
You asked the Plan to pre-approve right occipital nerve radiofrequency ablation. The Plan denied your request. The Plan says right occipital nerve radiofrequency ablation does not meet the Medicare NCD coverage criteria.
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 right occipital nerve radiofrequency ablation. Our reviewer says that the requested right occipital nerve radiofrequency ablation is not considered medically reasonable and necessary. Our physician reviewer found that radiofrequency ablation or cryoneurolysis of peripheral nerves to treat pain associated with occipital neuralgia or cervicogenic headache is considered investigational. No randomized controlled trials (RCTs) of RFA for chronic occipital neuralgia have been identified. Three RCTs of RFA for a cervicogenic headache have been published, none of which were high quality. Pain is a subjective, patient-reported measure that is particularly susceptible to a placebo effect. Randomized trials with sham or active controls are needed to evaluate the efficacy of this treatment. One controlled trial found a temporary benefit of cryoneurolysis for cervicogenic headache, but the effect was not significantly better than injection of corticosteroid and local anesthetic. The evidence is insufficient to determine the effects of the technology on health outcomes. The standard of care includes other modalities such as medication and therapy for symptom reduction. The review has determined that the requested right occipital nerve radiofrequency ablation is considered investigational. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right occipital nerve radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve right occipital nerve radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220), extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), and bitewing - 
single radiographic image (D0270) provided February 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the limited oral exam, periapical x-ray, tooth extraction and bitewing x-ray 
performed OON. You say that you were in pain and were unable to see your regular dentist. The Plan denied 
your request. The Plan says these services are not covered because they were performed OON. 
 
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 Plan covers the limited 
oral exam, periapical x-ray, tooth extraction and bitewing x-ray performed OON when the services are 
provided by a participating provider.  
We looked at the file and Medicare rules. In this case the services were provided OON. Based on this 
information, we decided that the Plan's rules for coverage of the limited oral exam, periapical x-ray, tooth 
extraction and bitewing x-ray performed OON have not been met. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic 
image (D0220), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including 
elevation of mucoperiosteal flap if indicated (D7210), and bitewing - single radiographic image (D0270) 
provided February 4, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported crowns (D6061 x 5). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says dental implants and all associated services are excluded from coverage. 
 
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 abutment supported 
crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve abutment supported crowns (D6061 x 5).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transcatheter placement of an intravascular stent (37239) 
and angiography services (75716-XU) provided on December 3, 2021. 
 
You asked the Plan to pay for the medical services as billed. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says the 
documentation does not support payment for the services 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 37239 is transcatheter placement of an intravascular 
stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty 
within the same vessel, when performed; each additional vein (List separately in addition to code for primary 
procedure). 
 
The CPT Code Manual definition of code 75716 is angiography, extremity, bilateral, radiological supervision 
and interpretation. 
 
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 medical services as billed. Our reviewer says that the 
documentation does not support payment for the services as billed. Our reviewer found for CPT 37239, the 
procedure report does not include documentation of additional vein. The procedure report states that "Right 
common iliac vein: Right common iliac vein IVUS, Right common iliac vein balloon angioplasty, Right 
common iliac vein and Mechanical Thrombolysis and Right common iliac vein Stent. Right proximal external 
iliac vein: Right proximal external iliac vein Stent." In this case, CPT 37239 cannot be verified in the 
documentation submitted. 
 
In this case, we have confirmed that code 75716 is a column II code to column I code 37238; however, 75716 
was billed with a modifier. Our coder found that although this procedure is documented in the operative report, 
the documentation does not support this procedure as separate from CPT 37238. Therefore, this would not be 
covered separately from 37238. 
 
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 medical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the transcatheter placement of an intravascular stent (37239) and angiography 
services (75716-XU) provided on December 3, 2021.
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 the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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 enrollee appears to be stable and improving and should only require short-term
additional acute care services that can be completed at the current facility until more appropriate for a lower
level of care. There are no services at the LTACH that the enrollee required that are not already available and
covered at the current facility. Transfer to LTACH is not medically necessary at this time as it would not be
clinically advantageous. Completion of treatment in the current facility is 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve elevating legrests (K0195).

You asked the Plan to pre-approve elevating legrests. You say that the legrest is required for you to use your wheelchair. The Plan denied your request. The Plan says that the information indicates that you do not have a musculoskeletal condition or the presence of significant lower extremity edema.

The Plan must follow Medicare rules. Medicare rules say that elevating legrests can be covered if Medicare criteria have been 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 elevating legrests. Our reviewer says that elevating legrests are not considered medically reasonable and necessary in this case. There is no documentation that you have a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee. There is no documentation that you have significant edema of the lower extremities that requires an elevating legrest. There is no documentation that you meet the criteria for and have a reclining back on the wheelchair. Our physician reviewer found that your condition does not meet Medicare criteria for elevating legrests.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of elevating legrests have not been met. Therefore, we decided that the Plan does not have to pre-approve elevating legrests (K0195).