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

 
We decided that the Plan does not have to pay for procedure codes 64447 and 64448 rendered on March 7, 
2023. 
 
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 these codes are part of the primary procedure and ineligible for separate payment. 
 
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 the denied codes is: 
 
CPT 64447: 
 
Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed 
 CPT 64448: 
 
Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections 
(includes imaging guidance, when performed) 
 
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 the medical record includes an 
anesthesia report with start time: 0730 and stop time: 0927, and injection service time begin 0738 and time end 
0742.  In this case, this procedure cannot be verified as a separate procedure, as both procedures were 
performed during same session. 
 
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 procedure codes 64447 and 64448 rendered on March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatry (eg, depression, anxiety, attention deficit 
hyperactivity disorder [ADHD]), genomic analysis panel (0345U). 
 
You asked the Plan to pre-approve psychiatry. 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 PGx tests are 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 psychiatry. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee's prescriber did not list 
preferred medication options for the enrollee that might be medications that would require gene testing to 
influence the treatment plan. Therefore, the LCD criteria was not sufficiently met for this testing.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychiatry have not been met. Therefore, we decided that the Plan does not 
have to pre-approve psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), 
genomic analysis panel (0345U).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (80307 and G0481) provided April 24, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. The medical records provided 
are missing a lab order/requisition. This means, the validity and accuracy of the claim cannot be verified. The submitted order does not include the specific drugs to be tested. Therefore, we decided that the Plan does not 
have to pay for the drug testing (80307 and G0481) provided April 24, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee will need physical therapy to be able to 
discharge home safely. The Plan denied your request. The Plan says the enrollee's condition does not meet the 
requirements for coverage of SNF 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from March 2, 2023, to March 31, 2023. 
 
You asked the Plan to pay for SNF care. You say that the services should be paid under the Medicare Act. The 
Plan denied your request. The Plan says the enrollee no longer had skilled nursing facility needs.  
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 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 that 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 or skilled therapy on an inpatient basis in a 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 pay for SNF care provided from March 2, 2023, to March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical removal of residual tooth roots - cutting 
procedure (D7250) Tooth #18, therapeutic parenteral drug, single administration (D9610), collection and 
application of autologous blood concentrate product (D7921) and guided tissue regeneration - resorbable 
barrier, per site (D4266) x2. 
 
You asked the Plan to pre-approve dental services. You say that you feel all the services should be covered 
because you have multiple infections. The Plan denied your request. The Plan says these services are not 
covered under your 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved the surgical removal of residual tooth roots - cutting procedure (D7250) Tooth 
#12 and 15. Therefore, this benefit has been exhausted with the approval. Therefore, we decided that the Plan 
does not have to pre-approve the surgical removal of residual tooth roots - cutting procedure (D7250) Tooth 
#18. 
 
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 the therapeutic parenteral drug, single administration (D9610), collection 
and application of autologous blood concentrate product (D7921) and guided tissue regeneration - resorbable 
barrier, per site (D4266) x2.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 27, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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 March 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from December 15, 2022, to January 13, 2022.

You asked the Plan to pay for the home health services. You say that the NOA was submitted timely. The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly denied. The Plan says that although your appeal indicated that the NOA was submitted, none has been received by the Plan.

The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of care date for home health services. NOAs which are received more than 30 days from the timely filing date result in no payment being made for the episode of care. 

In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from December 15, 2022, to January 13, 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 it would be unethical of the Plan to deny these much 
needed services for the enrollee. The Plan denied your request. The Plan says the enrollee's records do not 
show the rehabilitation needs are complex.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) 
x2 and pontic - porcelain/ceramic (D6245). 
 
You asked the Plan to pre-approve dental services. You say that you are in pain due to an infection and feel the 
services should be covered. The Plan denied your request. The Plan says these services are not covered under 
your Plan. 
 
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. Core buildup, including any 
pins when required (D2950) x2 and pontic - porcelain/ceramic (D6245) are not covered under the Plan's dental 
benefits 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2950 x2 and D6245 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
core buildup, including any pins when required (D2950) x2 and pontic - porcelain/ceramic (D6245).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 81518) rendered on 
March 24, 2023. 
 
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 submitted medical records do not contain sufficient detail to support the billed charges. 
 
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 81518 is "Oncology (breast), mRNA, gene expression 
profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-
embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit 
from extended endocrine therapy." 
 
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 this code represents 11 genes. 
However, the laboratory report does not include any documentation of the genes tested. Therefore, the code 
cannot be verified. 
 
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 laboratory services (procedure code 81518) rendered on March 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 28003 and 97605 rendered on February 3, 
2023. 
 
You asked the Plan to pay for the services. You say that the coding was appropriate. The Plan denied your 
request. The Plan says the operative report does not indicate that the wound vacuum used was durable medical 
equipment (DME). 
 
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 the denied codes is: 
 
CPT 28003: 
 
Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas  
CPT 97605: 
 
Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical 
equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per 
session; total wound(s) surface area less than or equal to 50 square centimeters 
 
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 in terms of CPT 28003, the 
provider reported two units of this service. The procedure report only supports one unit. The procedure was 
only performed on the left foot.  
 
In terms of CPT 97605, the procedure report does not include documentation of the type of device used. 
Therefore, this code cannot be verified. 
 
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 procedure codes 28003 and 97605 rendered on February 3, 2023.
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 services are both physically and medically 
necessary for the enrollee to return home at their maximum level of function with a decreased risk for 
readmission. The Plan denied your request. The Plan says the enrollee's needs may safely be met at a skilled 
nursing facility.  
 
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. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical therapy and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services. 
 
You asked the Plan to pay for acupuncture services. You say that you are paralyzed on your left side body. The 
Plan denied your request. The Plan says they will cover acupuncture for Medicare patients with chronic lower 
back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, Medicare will cover acupuncture for Medicare 
patients with chronic lower back pain. Therefore, we decided that the Plan does not have to pay for 
acupuncture services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that you have never had similar equipment. The 
Plan denied your request. The Plan says the information received indicates that there is the same or similar 
equipment already. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found that there is 
no information in the medical records that the enrollee is able to safely use this requested wheelchair. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar spine fusion, stereotactic computer-assisted 
(navigational) (SCAN) procedure; spinal (61783), and spinal bone allograft (22633, 61783, 20930). 
 
You asked the Plan to pre-approve a lumbar spine fusion, spinal SCAN procedure, and spinal bone allograft. 
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 a lumbar spine fusion, spinal SCAN 
procedure, and spinal bone allograft. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there is no documented spinal 
instability fracture or lesion. Fusion criteria 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 a lumbar spine fusion, spinal SCAN procedure, and spinal bone allograft have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar spine fusion, 
stereotactic computer-assisted (navigational) (SCAN) procedure; spinal (61783), and spinal bone allograft 
(22633, 61783, 20930).