Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) and a 
comprehensive oral evaluation (D0150) provided on May 18, 2021. 
 
You asked the Plan to pay for a panoramic radiographic image and a comprehensive oral evaluation. You say 
that your problem was urgent, because you had an accident and kept losing your teeth. You also say that the 
dentist did not come near you and that you were worked on by an intern. You also say that there were bones, 
nerves, and teeth left in your upper gums and the dentures never fit. The Plan denied your request. The Plan 
says a panoramic radiographic image (D0330) is allowed one procedure code from this group every five 
calendar years at 100% in-network. The Plan also says that a comprehensive oral evaluation (D0150) is allowed one procedure code form this group every three years at 100% in-network. The Plan also says that you 
already received these services on March 9, 2020, and the claim was paid correctly. The Plan says this benefit 
has 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. The Plan's contract says that a 
panoramic radiographic image (D0330) is allowed one procedure code from this group every five calendar 
years at 100% in-network, and a comprehensive oral evaluation (D0150) is allowed one procedure code form 
this group every three years at 100% in-network. 
 
We looked at the file, the Plan's rules, and Medicare's rules. The record shows that you already received a 
panoramic radiographic image (D0330) and a comprehensive oral evaluation (D0150) on March 9, 2020, 
therefore the benefit for these dental services have been exhausted. Therefore, we decided that the Plan does 
not have to pay for a panoramic radiographic image (D0330) and a comprehensive oral evaluation (D0150) 
provided on May 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the Intracept procedure is the only 
objective biomarker when treating patients with complaints of low back pain. You say that the Intracept 
procedure is safe, efficacious, durable, and reproducible for appropriately selected patients. You say that there 
are 15 peer-reviewed publications in 10 different scientific journals supporting the efficacy and safety of 
basivertebral nerve ablation with the Intracept procedure. The Plan denied your request. The Plan says this 
service is considered experimental/investigational as it is not widely used and not generally accepted for the 
suggested use as reported in nationally recognized peer-reviewed medical literature. 
 
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 Intracept procedure. Our reviewer 
says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are multiple plausible pathologic sources of significant pain generation. The 
non-radiating midline back pain and the diminished and painful spinal motion (in all directions) and intact 
neurologic exam are all non-specific to any pathologic entities. Overall, documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Documentation does not support 
actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or 
reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GTC-Hematology Profile Plus (81455) provided on February 
4, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that please reconsider payment of this claim 
based on medical necessity. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. Screening 
genetic testing is not a covered. 
 
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.  The records show that the enrollee resides in New Jersey and the provider is located in 
California. 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 GTC-Hematology Profile Plus (81455) provided on February 4, 
2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 25, 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 are not payable as billed. 
 
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 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 71045 provided on March 1, 
2022. 
 
You asked the Plan to pay for the medical services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim is a duplicate of 
a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 30, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the medical services as billed have not been 
met. Therefore, we decided that the Plan does not have to pay for the medical services coded 71045 provided 
on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on January 14, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the refraction. You say that the provider you saw is listed first in a search for in-
network providers on the Plan's website. The Plan denied your request. The Plan says this service was rendered 
by a provider who is not in the Plan's network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are rendered by a Plan-approved vision care provider. 
 
We looked at the file and the Plan's rules. The record shows that you received this service from an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the refraction have not 
been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on 
January 14, 2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle-foot orthoses (L1971) and heel stabilizers (L3170) 
provided on November 30, 2021. 
 
You asked the Plan to pay for ankle-foot orthoses and heel stabilizers. You say that the items at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS 
have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the enrollees medical record adequately supports the medical necessity for the item.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the available medical records do not discuss the items at issue. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for ankle-foot orthoses (L1971) and heel stabilizers (L3170) provided on 
November 30, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for progression of renal disease 
and initiation of hemodialysis. Your medical problems are stable. There are no complex nursing or 
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria 
for IRF care. 
 
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: Practitioner Services
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 the enrollee needs this to treat lower back pain. 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 laboratory services 
provided on February 10, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) surgery. 
 
You asked the Plan to pre-approve PVA surgery. You say that you can only sit up for 2 minutes. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because the record 
shows that you do not have an acute or subacute compression fracture. 
 
The Plan follows Medicare rules. Medicare rules state that PVA surgery is only covered if certain indications 
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 PVA surgery. Our reviewer says that 
you do not meet the Medicare criteria for PVA surgery. Our physician reviewer found there is no evidence that 
your vertebral fracture is acute and less than 6 to 12 weeks old. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation (PVA) surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. 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 office visit at issue in this appeal. The Plan did not pre-approve the 
office visit at issue. We found no exception that would require the Plan to pay for the office visit. Therefore, we 
decided that the Plan does not have to pay for office visit provided on February 28, 2022, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that the facet joint injections are medically 
necessary. The Plan denied your request. The Plan says the facet joint injections do not meet the Medicare 
coverage criteria.  
The Plan follows Medicare rules.  
 
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. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found RFA is expected to last at 
a minimum of 6 months with 50% pain relief. This was not achieved; therefore, 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the PT visits. You say that PT visits are medically necessary as the enrollee 
has had a significant decline in mobility and strength, causing increased care giver burden, and decreased 
overall quality of life. The Plan denied your request. The Plan says it is not medically necessary to approve 10 
additional visits until its known how the enrollee is responding to the first 10 PT visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 PT visits. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the requested services are not part of a maintenance program, and 
the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
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 PT visits. have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LINX Reflux Management System. 
 
You asked the Plan to pre-approve a LINX Reflux Management System. You say that the requested procedure 
is medically necessary and approved by the Food and Drug Administration (FDA). You say that the LINX 
Reflux Management System is a safe and effective fundic-sparing surgical treatment option for 
gastroesophageal reflux disease (GERD) that addresses the underlying mechanical and anatomical etiology of 
the disease and is associated with fewer side effects and complications. You say that this procedure is 
reversible and results in significantly shorter length of stay, less anesthesia time and comparable operative 
hospital costs compared to surgical fundoplication. The Plan denied your request. The Plan says this procedure 
is not considered reasonable and necessary for the treatment of GERD as the safety and efficacy of this 
procedure cannot be established by review of the available published peer reviewed medical literature. 
 
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 a LINX Reflux Management System. 
Our reviewer says that the LINX Reflux Management System is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee's available record documents gastroesophageal reflux on her acidity level study but not her upper gastrointestinal (UGI) series. No 
correlation however was provided of reflux events with the enrollee's symptoms. The enrollee's manometry 
results demonstrate normal tone and function of her lower esophageal sphincter (LES). As such, the 
appropriateness and necessity of surgical LES augmentation is not apparent in enrollee's case. The enrollee's 
history of bariatric surgery and of a hiatal hernia approaching 3cm in size are relative contraindications to 
optimal placement and safety of the LINX device. 
 
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 LINX Reflux Management System have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a LINX Reflux Management System.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve microsurgery services (69990). 
 
You asked the Plan to pre-approve microsurgery services (69990). The Plan denied your request. The Plan says 
this cannot be approved separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that pre-authorization for CPT code 69990 is not supported. Specifically, code 69990 is not separately 
payable with the requested procedure (63047). Based on this information, we decided that Medicare rules for 
authorization of the microsurgery services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve microsurgery services (69990).