Persius/hicric huggingface dataset:
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 needs LTACH care. The 
Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services requested do not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87798) provided on September 21, 
2022. 
 
You asked the Plan to pay for the lab services. You say that the services at issue have been billed correctly. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (87481, 87798) provided on September 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93312 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for procedure code 93312. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says payment for code 93312 is bundled into payment for 
code 00520. 
 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 93312 is a column II code to column I code 00520; however, 93312 
was billed with a modifier.  
 
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 procedure code 93312. Our reviewer says that procedure 
code 93312 does not meet criteria for payment in this case. Our reviewer found that the medical records 
indicate that code 00520 was performed on March 9, 2022. Code 93312 has a bundled relationship with 00520. 
A modifier is allowed to unbundle the two codes, providing the medical documentation supports the use of the 
modifier. In this case the medical records provided do not validate that code 93312 was performed as a separate 
and distinct service; therefore, the use of the 59 modifier is not appropriate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 93312 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 93312 billed for date of service March 9, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 4, 2022, to 
August 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says FIPS codes are missing. 
 
The Plan follows Medicare rules. The rules say that specific elements must be submitted on the claim.  
 
We reviewed the file and the Medicare rules. Review of the file shows that a FIPS code was not submitted on 
the claim. Based on this information, we find that the Medicare rules for payment of the claim at issue have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
August 4, 2022, to August 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (87505, 87491, 87493, 87500) provided on 
June 8, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the requested services were medically necessary, 
and you are requesting reimbursement for the services provided. The Plan denied your request. The Plan says 
the enrollee does not meet criteria. There is no documentation regarding the immune status of the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that there is no documentation that the enrollee is 
at risk of becoming seriously or critically ill or had severe or persistent diarrhea. Medicare rules say that the 
testing must be ordered from a clinician specialist and the records show that the ordering provider is a family 
medicine provider. The enrollee does not meet Medicare criteria for coverage of the requested testing. Based 
on this information, we decided that Medicare rules for coverage of genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (87505, 87491, 87493, 87500) 
provided on June 8, 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 needs intensive physical and 
occupational therapy services to return to his prior function of independent ambulation with wheelchair. The 
Plan denied your request. The Plan says the enrollee's records show that you do not require an intensive and 
coordinated interdisciplinary approach to your rehabilitation is not complex, medically necessary care may be 
provided safely in a different 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. Our 
physician reviewer found 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. 
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. 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 thermal destruction of the intraosseous BVN will be 
considered medically reasonable and necessary for the treatment of cLBP in patients who meet specific criteria. 
 
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 an Intracept procedure. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the enrollee does not meet the coverage criteria detailed in the LCD for Intracept 
intraosseous basivertebral nerve ablation at L5/S1. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Everolimus. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Everolimus.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950), maxillary partial denture  cast metal framework with resin denture bases (including any 
retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture  cast metal framework 
with resin denture bases (including any retentive/clasping materials, rests and teeth) (D5214). 
 
You asked the Plan to pre-approve. the dental services. You say that you need new dentures because chewing is 
painful; therefore, you are having a hard time eating. 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. The rules say dentures are 
limited to 1 upper complete/partial and/or 1 lower complete/partial denture every 5 calendar years including 
routine post-delivery care) includes necessary extractions to fit dentures (unlimited).  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2950 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve D2950. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested D5213 and D5214 was exhausted on date of service January 17, 2019. 
Therefore, we decided that the Plan does not have to pre-approve D5213and D5214.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 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 bone marrow aspirate remains experimental. More research is needed to show safety 
and efficacy when used as bone graft material. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you disagree with the denial. The Plan 
denied your request. The Plan says you are requesting an additional 15 miles for a total of 65 miles and your 
benefit only allows 50 miles. The Plan also says you have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 12 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare 
mileage (A0170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic-porcelain fused to high noble metal (D6240) 
for tooth #12 and #13, guided tissue regeneration (D4266) for tooth #15, and a bone replacement graft for ridge 
preservation (D7953) for tooth #15. 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration for the 
denial of the dental services. The Plan denied your request. The Plan says dental code D6240 is covered but 
does not comply with the established dental clinical criteria. The Plan says for a pontic (D6240) to be 
approved, the teeth that are holding the bridge must have a good long-term outcome. The Plan says based on 
the x-rays, the teeth are not healthy enough to support this service. Dental codes D4266 and D7953 are not 
covered by the 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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  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 dental services. Our reviewer says 
that the enrollee does not meet the Plan's coverage criteria for a pontic-porcelain fused to high noble metal for 
tooth #12 and #13. Our physician reviewer found the available documentation does not support that there is 
sufficient support around the proposed pontic-porcelain fused to high noble metal for tooth #12 and #13. It is 
not clear that the proposed crown preparation can achieve sufficient occlusal clearance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a pontic-porcelain fused to high noble metal (D6240) for tooth #12 and #13, guided 
tissue regeneration (D4266) for tooth #15, and a bone replacement graft for ridge preservation (D7953) for 
tooth #15.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0482 provided on September 20, 
2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation does not support the code 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 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 documentation supports 
nine drug classes were testing. This means the documentation does not support the testing of 15-21 drug 
classes. Based on this information, we decided that Medicare rules for coverage of the drug testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided 
on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (procedure code 99236) rendered on June 24, 
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 the documents do not support this level of care. 
 
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 99236 is "Hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires a 
medically appropriate history and/or examination and high level of medical decision making. When using total 
time on the date of the encounter for code selection, 85 minutes must be met or exceeded." 
 
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 examination was significant for 
right arm tenderness and diaphoresis, but the patient was awake and alert. The imaging revealed rib fractures and a clavicle fracture. The enrollee was treated conservatively. CPT 99236 was chosen but not sufficiently 
supported in the documentation. The history and examination was focused, but not comprehensive. Also, the 
records do not support medical decision making of high complexity as the patient was stable and required only 
conservative uncomplicated treatment. 
 
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 hospital care (procedure code 99236) rendered on June 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from April 1, 
2022, to April 30, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs shall no longer submit RAPS (Type of 
Bill 0322) for any HH period of care with a From date on or after January 1, 2022. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the claim at issue has been submitted 
alongside a RAP with Type of Bill 0322. This is not appropriate for dates of service on or after January 1, 
2022. Therefore, we decided that the Plan does not have to pay for home health services billed for dates of 
service from April 1, 2022, to April 30, 2022.