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

 
We decided that the Plan does not have to pay for the physician pathology services provided on December 27, 
2021. 
 
You asked the Plan to pay for the physician pathology services. You say that you have billed this claim with 
place of service (POS) code 22 as required by the Plan but feel this is incorrectly causing the denial of the TC 
of the services rendered. You believe that the global payment should be made for these services as the testing 
was performed on a stored specimen. The Plan denied your request. The Plan says the TC is not payable in the 
facility setting. 
 
The Plan must follow Medicare rules. Medicare rules say that an independent laboratory may not bill the 
Medicare contractor (and the Medicare contractor may not pay) for the TC of a physician pathology service 
furnished to a hospital inpatient or outpatient.  
 
We looked at the file and Medicare rules. These services were rendered for a hospital outpatient. Therefore, we decided that the Plan does not have to pay for the physician pathology services provided on December 27, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bitewings (D0274) and periodontal maintenance 
(D4910) provided by a participating provider. 
 
You asked the Plan to pre-approve bitewings and periodontal maintenance. You say that you would like the 
Plan to approve these services. The Plan denied your request. The Plan says the requested 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 pre-approve 
bitewings (D0274) and periodontal maintenance (D4910) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493 and 64494). 
 
You asked the Plan to pre-approve facet joint injections (64493 and 64494). You say that the requested facet 
joint injections (64493 and 64494) are medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for the requested facet joint injections (64493 and 64494). 
 
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 facet joint injections (64493 and 64494). Our reviewer says that the enrollee does not meet criteria for the requested facet joint injections (64493 
and 64494). Our physician reviewer found records do not demonstrate an absence of untreated radiculopathy or 
neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst) AND that there is no 
non-facet pathology per clinical assessment or radiology studies that could explain the source of the enrollees 
pain, including but not limited to fracture, tumor, infection, or significant deformity. The request does not 
comply with these criteria and therefore, the request is deemed 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 facet joint injections (64493 and 64494) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve facet joint injections (64493 and 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99310) provided on March 17, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that it is the responsibility of the hospital staff 
to obtain authorization. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advance. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility care (99310) provided on 
March 17, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bariatric 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 this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a history of prior gastric bypass with normal anatomy. The placement of a 
laparoscopic gastric band over gastric bypass is not a standard procedure. The enrollee has no current comorbid 
conditions, and has not documented any efforts at weight loss, such as medication use. The primary criteria for 
treatment of morbid obesity at this time is not 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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bariatric surgery for the enrollee.
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 enrollee currently meets acute 
LTACH hospital admission criteria under current CMS guidelines. The Plan denied your request. The Plan says 
authorization denied because the LTACH is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient 
setting, or home care. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 
 
 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of desensitizing resin (D9911), 
unspecified restorative procedure (D2999), and pulp cap (D3120). 
 
You asked the Plan to pre-approve desensitizing resin, a restorative procedure, and pulp cap. You say that  The 
Plan denied your request. The Plan says the application of desensitizing resin (D9911) and unspecified 
restorative procedure (D2999) are not covered by your dental benefits. The Plan also says that a pulp cap 
(D3120) is only covered if you are between the ages of 0-20. 
 
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 the 
application of desensitizing resin (D9911), unspecified restorative procedure (D2999), and pulp cap (D3120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve a lumbar epidural steroid injection. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when specific criteria 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 a lumbar epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there was no 
documentation of significant degenerative disc disease (DDD) on imaging. This does not appear to meet the 
criteria for coverage at this time. The request is considered 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 a lumbar epidural steroid injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion, normal saline solution, 1000 cc (CPT J7030), Intravenous Infusion, hydration; each additional hour (CPT 96361) and Infusion, normal saline solution, 250 cc (CPT J7050) provided on December 21, 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 the fluid used to administer the drug is incidental hydration and not separately payable based on the Medicare LCD coverage criteria.

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the medical record does not support a diagnosis of medical necessity, and this would therefore incidental hydration. In this case, this service would not be reported and reimbursed separately. 

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 infusion, normal saline solution, 1000 cc (CPT J7030), Intravenous Infusion, hydration; each additional hour (CPT 96361) and Infusion, normal saline solution, 250 cc (CPT J7050) provided on December 21, 2021.
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 the review indicates that the complexity of the enrollee's nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: 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 that the enrollee requires inpatient care due to 
weakness. The Plan denied your request. The Plan says authorization denied because the IRF care is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). 
 
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 the record indicates that the complexity of the enrollee's nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee does not require treatment by multiple therapies. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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 April 26, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transversus abdominis plane (TAP) block (procedure code 
64486) provided to the enrollee on March 3, 2022. 
 
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 Current Procedural Terminology (CPT) code 64486-59-RT (1 Unit) remains 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 64486 is [*****enter CPT Codebook definition*****]. 
 
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 that the procedure report does not 
indicate that this procedure was performed post-operative pain management and at the surgeon's request. 
Therefore, this procedure cannot be verified as not performed as part of the anesthesia for the 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 have not been met. Therefore, we decided that the Plan does not 
have to pay for a transversus abdominis plane (TAP) block (procedure code 64486) provided to the enrollee on 
March 3, 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 enrollee meets the criteria for inpatient 
rehabilitation. The enrollee will not be able to return to her previous independent living without the intensive 
therapy provided in an inpatient rehabilitation program. The Plan denied your request. The Plan says 
authorization denied because the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility (SNF). 
 
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 there are no acute rehabilitation nursing needs identified or documented. At the 
current functional level, the enrollee does not need intensive therapies consisting of at least three hours of 
therapy per day at least five days per week with multidisciplinary approach in an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported removable denture (D6110). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 11, 2020. 
Therefore, we decided that the Plan does not have to pre-approve an implant supported removable denture 
(D6110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of desensitizing medicament (D9910) and 
pulp vitality tests (D0460) provided on May 5, 2022. 
 
You asked the Plan to pay for the application of medicament and vitality tests. You say that you were not told 
these services were not covered. The Plan denied your request. The Plan says that the application of 
desensitizing medicament (D9910) and pulp vitality tests (D0460) are not covered by your 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 the 
application of desensitizing medicament (D9910) and pulp vitality tests (D0460) provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a permanent upper partial denture on May 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told that you could not get your new 
partial that day because you still owed $2,000. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 May 18, 2021. Therefore, 
we decided that the Plan does not have to pay for a permanent upper partial denture on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) and a complete maxillary denture 
(D5110) provided on March 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were performed based on the 
predetermination and reconsideration. 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 Plan's 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 panoramic x-ray (D0330) and a complete maxillary denture (D5110) provided on March 23, 2022.