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

 
We decided that the Plan does not have to pay for procedure code 99239 for date of service May 8, 2023. 
 
You asked the Plan to pay for procedure code 99239. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the code at issue is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the code definition is time-
based, and the records submitted for review do not document the total time spent providing the services 
described by this code. Based on this information, we decided that Medicare rules for coverage of procedure code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99239 for date of service May 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on January 12, 2023, billed 
with codes 87481, 87500, 87640, 87653 and 87798. 
 
You asked the Plan to pay for the laboratory testing billed. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one HCPCS/CPT 
code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if a laboratory procedure produces multiple reportable 
test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This was a panel test that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the laboratory testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing 
provided on January 12, 2023, billed with codes 87481, 87500, 87640, 87653 and 87798.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) for tooth number 6 and scaling 
and root planing (D4341) for the upper left quadrant. 
 
You asked the Plan to pre-approve core buildup (D2950) for tooth number 6 and scaling and root planing 
(D4341) for the upper left quadrant. You say that you approved the crowns but not the buildup for teeth for 
crowns. You also say you do not have a lot of extra money. The Plan denied your request. The Plan says the 
criteria for scaling and root planing (D4341) for the upper left quadrant has not been met because there is no x-
ray image of the upper left quadrant submitted for review. The Plan also says that the pre-determination 
estimate of benefits shows that only a core build up was submitted for tooth number 6. The Plan also says that 
there was no crown procedure requested for tooth number 6, which is the primary procedure.  
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of core buildup (D2950) for tooth number 
6 and scaling and root planing (D4341) for the upper left quadrant have been met. There were no x-rays 
received for the requested service of scaling and root planing (D4341). X-rays are needed to determine if the 
service is necessary. Also, there was no crown procedure requested for tooth number 6, which is the primary 
procedure. Therefore, the core buildup (D2950) on tooth number six has not met the criteria.. Therefore, we 
decided that the Plan does not have to pre-approve core buildup (D2950) for tooth number 6 and scaling and 
root planing (D4341) for the upper left quadrant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01992-QY-P3 billed for date of service 
March 8, 2023. 
 
You asked the Plan to pay for the billed service. You say that the claims are separate reimbursable claims. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
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 shows that the services at issue were reimbursed by the Plan 
on March 25, 2023. A comparison of the two claims shows the claim lines are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date.  
 Based on this information, we decided that the Medicare rules for the billed service have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 01992-QY-P3 billed for date of 
service March 8, 2023.
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 is currently stable for 
transfer to a LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-
patient acute care and does not require transfer to a Long-Term Acute Care Hospital. 
 
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 the records show the enrollee having Parkinson's, dysphagia, atrial fibrillation, and 
chronic obstructive pulmonary disease and was admitted with septic shock from worsening sacral wound 
infection and necrotizing fasciitis requiring debridement and wound ac placement and a PEG tube placed. The enrollees wound care is not complex and requires thrice weekly wound vac changes and does not meet criteria 
for LTACH admission.  
 
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: 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 with the enrollee's medical complexity, you do not 
feel they could be cared for safely in skilled nursing. The Plan denied your request. The Plan says the requested 
service is not medically necessary.  
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve traction equipment, cervical, free-standing stand/frame, 
pneumatic, applying traction force to other than mandible (E0849). 
 
You asked the Plan to pre-approve traction equipment. You say that you had back surgery in 1981. You deny 
any follow-up at this time. You attempted physical therapy, but it was not effective. The pain in your neck 
remains and is average. The Plan denied your request. The Plan says you do not meet criteria for approval of 
the requested device. 
 
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 traction equipment. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested device would be covered if you have a musculoskeletal condition (long 
term pain in the bones, joints, ligaments, tendons, or muscles) or neurologic condition (related to brain and 
nerve function) requiring traction equipment; or if you have been shown the device and have tolerated the use 
of the device. The review has determined that you do not meet criteria for the requested device. The requested 
device 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 traction equipment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction 
force to other than mandible (E0849).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment with bupivacaine provided on August 24, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that you have billed the services at issue 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 the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery.  
 
We looked at the file and Medicare rules. Payment for the services at issue is included in the global surgery 
payment for the procedure (62323) provided on the same date of service. Based on this information, we 
decided that Medicare rules for coverage of the services at issue have not been met. Therefore, we decided that 
the Plan does not have to pay for treatment with bupivacaine provided on August 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Incomplete endodontic therapy (D5224). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
Incomplete endodontic therapy (D5224).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the reason your physician put you on the hold was 
to rest and not do physical therapy to help the healing process, you are now being discharged and have no one 
at home to help. The Plan denied your request. The Plan says there is no clinical evidence to support the 
medical necessity of skilled nursing services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 
10, 2023, to April 8, 2023. 
 You asked the Plan to pay for the SNF care. You say that the SNF stay should be covered under the Medicare 
Act. The Plan denied your request. The Plan says the enrollee did not meet the criteria for the SNF stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from March 10, 2023, to April 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for NeuroIDgenetix (81479) provided June 13, 2023. 
 You asked the Plan to pay for the genetic testing. You say that please review the attached documentation and 
reprocess for payment. The Plan denied your request. The Plan says the request for NeuroIDgenetix does not 
meet Medicare rules and is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee is suffering from Bipolar Disorder Mixed, Moderate, Generalized Anxiety 
Disorder and Insomnia. This enrollee is currently not on any psychotropic medications for which there is more 
than one known gene-drug interaction. Utilizing the information from Medicare LCD L38377 it does not 
appear that the NeurolDgenetix Psychotropic Assay is considered medically necessary and reasonable in the 
treatment of this individual as this diagnosis is not considered medically necessary for this procedure. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for NeuroIDgenetix (81479) provided June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an advanced pneumatic compression device (PCD) (E0652) with 
accessories. 
 
You asked the Plan to pre-approve advanced PCD. You say that this is the best way to help the enrollee. The 
Plan denied your request. The Plan says that the records do not show that the lymphedema extends into the 
abdomen, that the enrollee has failed conservative treatment, or that the bene had a month-long trial of a basic 
pump. 
 
The Plan follows Medicare rules. Medicare rules state that an advanced PCD may be covered if certain criteria 
are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve advanced PCD. Our reviewer says that 
the enrollee meets criteria for this device. Our physician reviewer found the records include physical therapy 
notes demonstrating failure of previous treatment, abdominal edema, and a month-long trial of a basic pump. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of advanced PCD have been met. Therefore, we decided that the Plan has to pre-
approve an advanced pneumatic compression device (PCD) (E0652) with accessories.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve L1 kyphoplasty (22513, C1062). 
 
You asked the Plan to pre-approve L1 kyphoplasty. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve L1 kyphoplasty. Our reviewer says that 
the enrollee does not meet criteria for coverage. Our physician reviewer found detailed documentation is not 
evident regarding the worsening of pain. Additionally, there is no documentation of a progression of the body 
height loss, greater than 25% vertebral body height loss, kyphotic deformity, or a severe impact on daily 
activities. Moreover, there is magnetic resonance imaging (MRI) corroboration of retropulsion and other 
plausible causes of pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of L1 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve L1 kyphoplasty (22513, C1062).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve oral surgical splint. 
 
You asked the Plan to pre-approve oral surgical splint. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that the enrollee does not meet the requirements for 
approval.  
 
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 oral surgical splint. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the review of the submitted documentation indicates that a diagnosis of arthritis if the 
bilateral temporomandibular joints (TMJ) is the causative factor in the enrollees pain. Placement of an 
occlusal splint is medically reasonable and necessary as a conservative treatment modality. The diagnosis of 
arthritis of the TMJ is a medical issue and not a dental condition being treated.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oral surgical splint have been met. Therefore, we decided that the Plan has to 
pre-approve oral surgical splint.  
 
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.