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

 
We decided that the Plan does not have to pay for inpatient care (99231) provided on April 1, 2022. 
 
You asked the Plan to pay for the inpatient care. You say that this service was medically necessary. 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 April 27, 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 inpatient care have not been met. 
Therefore, we decided that the Plan does not have to pay for inpatient care (99231) provided on April 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic - porcelain fused to predominantly base metal 
tooth #'s 19, 28, and 29 (D6241), and retainer crown - porcelain fused to predominantly base metal tooth #'s 18, 
20, 27 and 30 (D6751). 
 
You asked the Plan to pre-approve the pontic - porcelain fused to predominantly base metal tooth, and retainer 
crown - porcelain fused to predominantly base metal. You say that you need the procedure because your teeth 
are separating. The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 pontic - 
porcelain fused to predominantly base metal tooth, and retainer crown - porcelain fused to predominantly base 
metal 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 pontic - porcelain fused to 
predominantly base metal tooth (D6241), and retainer crown - porcelain fused to predominantly base metal 
(D6751). Our reviewer says that these services are not medically necessary. Our physician reviewer found 
coverage for fixed bridges are considered only to replace a single maxillary anterior tooth or two adjacent 
mandibular anterior teeth. In this case the teeth to be replaced are bilateral posterior mandibular teeth. The 
documentation provided does not meet the criteria for coverage for fixed bridges to replace the missing 
mandibular posterior teeth. The documentation provided does not meet the criteria for coverage for fixed 
bridges to replace the missing mandibular posterior teeth (#'s 19, 28 and 29). 
 
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 pontic - porcelain fused to predominantly base metal tooth, and retainer 
crown - porcelain fused to predominantly base metal have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a pontic - porcelain fused to predominantly base metal tooth #'s 19, 28, and 29 
(D6241), and retainer crown - porcelain fused to predominantly base metal tooth #'s 18, 20, 27 and 30 (D6751).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 21, 2021. 
 
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 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 October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 11, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to end-stage renal disease (ESRD) provided on 
November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 3, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to end-stage renal disease (ESRD) provided on August 
3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on 
February 7, 2022, through February 16, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the denial and 
have submitted medical records for review. The Plan denied your request. The Plan says the requested device is 
not covered per Medicare guidelines. 
 
The Plan follows Medicare rules. The rules say that a PCD coded as E0675 to treat peripheral arterial disease is 
not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on February 7, 2022, through February 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on June 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement between the laboratory and the dialysis facility regarding payment. The Plan denied your request. 
The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to end-stage renal disease (ESRD) provided on June 28, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 1, 2022 to 
March 30, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the home health services were 
medically necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. 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 March 1, 2022 to March 
30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Verio diabetic test strips. 
 You asked the Plan to pre-approve OneTouch Verio strips. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested diabetic test strips are a 
non-preferred brand. 
 
The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of OneTouch Verio strips have not been met. Specifically, the requested items are a non-preferred 
brand. The case record does not contain medical documentation that supports the medical necessity of the 
requested items. Therefore, we decided that the Plan does not have to pre-approve OneTouch Verio diabetic 
test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
You asked the Plan to pre-approve genicular nerve blocks. You say that you are not able to do basic activities 
due to pain and discomfort. The Plan denied your request. The Plan says this procedure is 
experimental/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 genicular nerve blocks. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the role of genicular nerve blocks in post-arthroplasty knee pain is the subject of 
ongoing clinical trials. 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve blocks.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 1, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene expression services coded 0089U provided on 
January 29, 2021. 
 
You asked the Plan to pay for the gene expression services. You say that you disagree with the Plan's denial. 
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 September 23, 2021. 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 gene expression services have 
not been met. Therefore, we decided that the Plan does not have to pay for the gene expression services coded 
0089U provided on January 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says the requested neuropsychological testing 
does not meet the Medicare LCD 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 neuropsychological testing. Our 
reviewer says that neuropsychological testing is not medically necessary in this case. Our physician reviewer 
found that based on review the records provided, the provider is requesting neuropsychological testing for Mild 
Cognitive Impairment of Uncertain or Unknown Etiology. Utilizing the criteria from LCD L33632 that this 
testing is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge 
directly on or indirectly on the brain including detection of neurologic disease based on quantitative assessment 
of neurocognitive abilities, differential diagnosis between psychogenic and neurogenic syndromes, delineation 
of neurocognitive effects of central nervous system disorders, neurocognitive monitoring of recovery or 
progression of central nervous system disorders or assessment of neurocognitive function for the formulation of 
rehabilitation and/or management strategies among individuals with neuropsychiatric disorders. This enrollee 
was previously diagnosed with dementia from Alzheimers type per his medical notes. Based on this 
information provided, it is therefore not medically necessary or reasonable to have of neuropsychological 
testing performed as it will not impact the patients medical management of his memory issues. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care to be provided by an OON provider. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial for SNF care. The Plan 
denied your request. The Plan says that the requested services are not covered when provided by an OON 
provider. The Plan also says that SNF care is available 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
SNF care to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer system 
(22869). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that you are appealing the Vertiflex 
procedure. You have no quality of life anymore and cannot walk more than 20 feet. You need something and 
you were told this would be your best choice. The Plan denied your request. The Plan says this procedure is 
considered experimental and investigational as there is no proven clinical efficacy in the established medical 
literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  The rules also say that experimental and investigational devices are not covered. 
 
 
 
 
 
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Vertiflex Superion interspinous spacer system (22869).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the critical care services rendered on February 18, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that payment for the services is included in the fee for the procedure. 
 
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. The Plan states that payment for code 99291 is included in the fee for the 
procedure; however, the claim submitted does not contain any documentation of a separate procedure code 
billed for the date of service at issue. The Plan has not provided any documentation to support that 99291 
cannot be paid as billed. Therefore, we decided that the Plan has to pay for the critical care services rendered on 
February 18, 2022.  
 
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 related to end-stage renal disease 
(ESRD) provided on July 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were 
medically necessary. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services related to end-stage renal disease (ESRD) provided on July 7, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S1015 and S8301 billed for date of service 
September 14, 2022. 
 
You asked the Plan to pay for procedure code S1015 and S8301. The Plan denied your request. The Plan says 
the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S1015 and S8301 has a Status Indicator of I on the Physician Fee Schedule. This 
means that procedure code S1015 and S8301 is not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of procedure code S1015 and S8301 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code S1015 and S8301 billed for date of service 
September 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (82728, 83540, 83550) related to 
ESRD provided on May 24, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services at issue have 
been billed correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 laboratory services (82728, 83540, 83550) related to ESRD provided on May 24, 
2022.