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

 
We decided that the Plan does not have to pay for the Nursing facility discharge day management (99316) 
provided on January 18, 2021. 
 
You asked the Plan to pay for code 99316. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99316. 
 
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 99316 is Nursing facility discharge day management; 
more than 30 minutes. 
 
We find that CPT code 99316 is not supported in the medical record. Specifically, there are no supporting 
records showing that more than 30 minutes of nursing facility discharge day management was provided on 
January 18, 2021. Based on this information, we decided that Medicare rules for coverage of code 99316 have not been met. Therefore, we decided that the Plan does not have to pay for the Nursing facility discharge day 
management (99316) provided on January 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483) provided on January 24, 2022. 
 
You asked the Plan to pay for code G0483. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the records do not support the billing of code G0483. 
 
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 G0483 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; 22 or 
more drug class(es), including metabolite(s) if performed. 
 We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not contain 
evidence that definitive testing on 22 or more drug classes was performed. Based on this information, we 
decided that Medicare rules for coverage of code G0483 have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing (G0483) provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on November 23, 
2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every 
HCPCS code. 
 
Medicare rules say that the I/OCE edits all outpatient hospital claims. OCE edit 21 is applied when a procedure 
(type T or S) is billed on the same day as an E&M service (type V) without modifier -25 being added to the 
E&M service. We looked at the file and Medicare rules. Code G0463 is type V, an E&M service. It was billed 
on the same date as 71260 and 74177 which are type S. Modifier -25 was not appended as required. 
 
Code G1004 has an OPPS status indicator of E1 and is not payable in the outpatient clinic setting. Therefore, 
we decided that the Plan does not have to pay for the outpatient hospital services provided on November 23, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the ultrasonic guidance for needle placement (76942) provided on 
October 11, 2021. 
 
You asked the Plan to pay for the ultrasonic guidance for needle placement. You say that you would like this 
claim reprocessed as this code is eligible for separate payment. The Plan denied your request. The Plan says 
that charges for or in connection with services or supplies that are considered to be experimental or 
investigational are excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied coverage as being in connection with services or 
supplies that are considered to be experimental or investigational. The Plan has failed to substantiate their 
denial as it is not clear under what medical reasoning these services are being denied as experimental or 
investigational.  Therefore, we decided that the Plan has to pay for the ultrasonic guidance for needle placement 
(76942) provided on October 11, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a kidney transplantation (and donor nephrectomy). 
 
You asked the Plan to pre-approve a kidney transplantation (and donor nephrectomy). You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services 
are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 kidney transplantation (and donor 
nephrectomy). Our reviewer says that the requested items/services are considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has an eGFR of under 20. Criteria for listing 
for kidney transplantation is eGFR under 20.  This is the standard of care benchmark and this enrollee is in the 
range of kidney function where evaluation for kidney transplantation is indicated. The reasoning of denial in no 
way reflects what would be considered standard practice in the management of enrollees with advanced chronic 
kidney disease. Therefore, the enrollee is appropriate for evaluation for transplant and donor nephrectomy. 
 
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 kidney transplantation (and donor nephrectomy) have been met. Therefore, we 
decided that the Plan has to pre-approve a kidney transplantation (and donor nephrectomy).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 1, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 laboratory services provided on December 1, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LINX procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure restores the esophageal 
sphincter without major side effects. The Plan denied your request. The Plan says the procedure 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 the requested services. Our physician 
reviewer found that the available records do not support the medical necessity nor appropriateness, nor justify 
the enrollees procedural risks, of surgical augmentation of the lower esophageal sphincter. The enrollee has 
some symptoms that correlate with gastroesophageal reflux. He has an intact lower esophageal sphincter that 
does not require augmentation, and the degree of esophageal injury attributable to gastroesophageal reflux 
disease (GERD) is histologically negligible. In addition, the enrollees esophageal dysmotility is a relative 
contraindication to LINX implantation. Therefore, the requested procedure is not medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a LINX procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
on November 23, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that the claim should be paid in full. You 
also say that the services were authorized. The Plan denied your request. The Plan says the self-administered 
drugs were denied correctly. 
 
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 pay for the self-administered drugs 
provided in an outpatient setting on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635). 
 
You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan follows Medicare rules. Medicare rules say that repeat ablation at the same anatomic site is 
considered medically reasonable and necessary provided the patient had a minimum of consistent 50% 
improvement in pain for at least six (6) months. 
  
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 radiofrequency ablation procedure. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee 
previously received bilateral L3-5 facet radiofrequency ablation with a reported pain reduction duration of only 2.5 months. Coverage criteria for an additional procedure 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 radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on November 8, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test report includes treatment options for 
mutated biomarkers. The Plan denied your request. The Plan says the service does not meet the coverage 
requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The records provided do not show that tissue based CGP is 
infeasible. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on 
November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0210, D4355) provided on January 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
under your supplemental dental coverage. 
 
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 dental 
services (D0210, D4355) provided on January 19, 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 IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and your needs can be met at a lower level of 
care such as in a skilled nursing facility, at home with home health services or with outpatient therapy. 
 
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 that while you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program such as 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 pay for a crown (D2740 and D2751) provided by a participating 
provider on January 3, 2022. 
 
You asked the Plan to pay for a crown. You say that you do not agree with these charges. The Plan denied your 
request. The Plan says the correct coinsurance has been applied. 
 
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 a crown with 
a 50% coinsurance. 
 
We looked at the file and Medicare rules. A 50% coinsurance of the allowed amount for the services provided 
has been correctly applied. Based on this information, we decided that the Plan's rules for coverage of a crown 
have been met and applied corrected. Therefore, we decided that the Plan does not have to pay for a crown 
(D2740 and D2751) provided by a participating provider on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  an intraoral examination (D0220), endodontic therapy 
(D3310), ceramic crown (D2740), and core build up (D2950) provided on February 15, 2022. 
 
You asked the Plan to pay for  an intraoral exam, therapy, crown, and core build up. You say that you are in 
pain and need to have your tooth fixed. The Plan denied your request. The Plan says that an intraoral 
examination (D0220), endodontic therapy (D3310), ceramic crown (D2740), and core build up (D2950) are not 
covered by your 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  an 
intraoral examination (D0220), endodontic therapy (D3310), ceramic crown (D2740), and core build up 
(D2950) provided on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental crown (D6791) and pontic (D6211) provided on 
January 12, 2022. 
 
You asked the Plan to pay for a dental crown and pontic. You say that you were informed by the 
representatives if you purchased enhanced dental coverage crowns would be covered by 50%. The Plan denied 
your request. You called the Plan after the services were rendered. The Plan says this service is not covered by 
the Plan's 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 a dental 
crown (D6791) and pontic (D6211) provided on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G device. 
 
You asked the Plan to pre-approve a MyoPro Motion G device. You say that the requested device is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested equipment is considered 
investigational/experimental. 
 
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 MyoPro Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 61-year-old male with a past medical history of brain stem 
contusion with right upper extremity weakness. Based on current clinical guidelines and review of the peer-
reviewed medical literature, robotic therapy has been designated to be of "uncertain utility compared with dose-
matched conventional upper limb exercise therapies" with unproven benefit in the home environment. 
 
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 MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921), fluoride varnish (D1206), 
periodontal scaling and root planing (D4341), and delivery of antimicrobial agents (D4381) provided on 
January 27, 2022. 
 
You asked the Plan to pay for gingival irrigation (D4921), fluoride varnish (D1206), periodontal scaling and 
root planing (D4341), and delivery of antimicrobial agents (D4381). You say that you are appealing the denial 
for the services you received. The Plan denied your request. The Plan says you are covered for supplemental 
dental benefits however prior authorization requirements may apply. 
 
 
 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. Prior authorization is required. 
 
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. The antimicrobial agents, gingival irrigation, and dental 
drugs/medicaments arent included in the plans covered dental benefits. Therefore, we decided that the Plan 
does not have to pay for gingival irrigation (D4921), fluoride varnish (D1206), periodontal scaling and root 
planing (D4341), and delivery of antimicrobial agents (D4381) provided on January 27, 2022.