Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified adjunctive procedure (D9999) provided on 
February 21, 2023. 
 
You asked the Plan to pay for 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 pay for an 
unspecified adjunctive procedure (D9999) provided on February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 2, 2023, to May 30, 
2023, by a non-network provider. 
 
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 the services were rendered by a non-network provider without prior authorization. 
 
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 May 2, 2023, 
to May 30, 2023, by a non-network provider.
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 would benefit from LTACH 
care. The Plan denied your request. The Plan says the enrollee's care can be provided at the current facility until 
they are more stable, for transfer to another level of care. 
 
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 enrollee appears to be currently managed at an intensive care level with 
continuous intravenous sedation which has a high risk of hemodynamic instability. The enrollee is also 
receiving hemodialysis due to renal failure. There do not appear to be any services available at the LTACH that are not currently available at the enrollee's present location. The enrollee also does not appear to be stable for 
transfer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80307 and G0480) provided October 
14, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says Z79.891 and F11.20, should not be reported together. 
 
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 laboratory services have not been met. The diagnosis codes 
associated to Z79.891-long term (current) use of opiate analgesic and F11.20 - opioid dependence, 
uncomplicated, should not be reported together which is based on the Excludes1 Notes instructions in the ICD-
10-CM Official Guidelines for Coding and Reporting. The billed service has been denied because it was 
reported with one or more diagnosis code pairs that are subject to an Excludes1 note.  Therefore, we decided 
that the Plan does not have to pay for the laboratory services (80307 and G0480) provided October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation therapy. 
 
You asked the Plan to pre-approve radiation therapy. 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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found radiation treatment is not medically reasonable and necessary in this case. The 
records do not show that you have consulted with a radiation oncologist confirming the necessity of this 
treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiation therapy.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a diagnostic nuclear medicine test-non cardiac vascular 
flow. 
 
You asked the Plan to pre-approve a diagnostic nuclear medicine test-non cardiac vascular flow. You say that a 
diagnostic nuclear medicine test-non cardiac vascular flow is medically necessary. The Plan denied your 
request. The Plan says the requested diagnostic nuclear medicine test-non cardiac vascular flow 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 pre-approve a diagnostic nuclear medicine test-non 
cardiac vascular flow. Our reviewer says that the requested diagnostic nuclear medicine test-non cardiac 
vascular flow is not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not support the medical necessity of the procedure in question due to lack of 
clarity and a possible coding error. The recommendation is for a single-photon emission computed tomography 
(SPECT) test for underlying ischemia however, it is not articulated what part of the body is being 
imaged. Based on the note in general and overall assessment it appears that this is meant to be a cardiac study. 
However, code 78445 specifically codes for noncardiac vascular imaging. Recommendation is to resubmit the 
request to the Plan with clarity regarding what is to be imaged, and use of a code that matches the body 
territory in question.  
 
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 diagnostic nuclear medicine test-non cardiac vascular flow have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a diagnostic nuclear medicine test-non 
cardiac vascular flow.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95937 rendered on April 3, 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 code is not appropriate for the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95937 is "Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method."  
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 procedure report does not 
include documentation of neuromuscular junction testing. For CPT 95937 The provider performs 
neuromuscular junction testing by repetitive stimulation of a nerve supplying a muscle to diagnose a patient 
with a known or suspected disorder of the neuromuscular junction. It is not appropriate to bill separately for 
train-of-four (TOF) monitoring. The American Medical Association (AMA) has clearly stated that CPT code 
95937 is not appropriate for this procedure, nor may TOF monitoring be billed with an unlisted code. 
 
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 code 95937 rendered on April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection(s), diagnostic or therapeutic agent, paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar 
or sacral; single level (64493) provided June 7, 2023. 
 
You asked the Plan to pay for the service. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not 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 pay for the service. Our physician reviewer found 
the LCD states that facet blocks are indicated when there is an, "Absence of untreated radiculopathy or 
neurogenic claudication". There are radicular symptoms, and the procedure was not medically reasonable and 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 
nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) 
provided June 7, 2023.
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 coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is covered when the 
criteria listed in the Medicare rules section of this decision 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 neuropsychological testing. Our 
reviewer says that the requested neuropsychological testing is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation presented does not agree with the 
Medicare LCD for this case as all psychological tests should be administered, scored and interpreted by a 
trained professional including a psychologist, clinical psychologist or advanced nurse practitioner with 
education in the area or a physician assistant who works with the psychiatrist with expertise in the appropriate 
area. Utilizing the criteria from the Medicare LCD 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 does not meet the criteria as it is 
unclear the reasoning for the testing to be obtained. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 6, 2023, billed with 
codes 81162, 81201, 81209, 81218, 81242, 81272, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81345, 
81351, 81479, and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 6, 2023, billed with codes 81162, 81201, 81209, 81218, 81242, 81272, 81295, 81298, 81307, 81314, 
81317, 81321, 81334, 81345, 81351, 81479, and 81292.
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 you must use a brace and are unable to get the brace 
on and off by yourself. You feel that you would benefit from SNF care and therapy to attain your prior level of 
independence. The Plan denied your request. The Plan says the skilled nursing facility (SNF) services 
requested do not meet the requirements for approval. 
 
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 any parental medication; complex wound care or nutrition given via 
a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your 
physical function is at or near your baseline and you can receive services at a lower level of care. Admission to 
a SNF for inpatient skilled rehabilitation services 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 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health physical therapy visits (G0151 x16). 
 You asked the Plan to pre-approve home health services. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found as of 
September 22, 2023, the enrollee was independent with transfers and ambulation over 200 feet with no 
assistive device and supervision for uneven surfaces and stairs. Based on the available records the enrollee 
appears to have improved with therapy to the point of being able manage independently with activities as 
described above. After the previously approved therapy treatments, records do not support that the complexity 
of the enrollee's conditions are such that the skills of a professional therapist are required to achieve further 
improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program 
appears appropriate at this point. Provided records do not document any acute or unstable medical conditions or 
injuries which would necessitate any further skilled therapy visits beyond what have already been approved. 
Records document the enrollee has been educated on a home exercise program. No medical notes from the 
enrollee's treating physician are provided documenting an order or need for additional skilled therapy services. 
The enrollee is walking community distances, transition to outpatient physical therapy appears appropriate if 
further therapy is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the home health physical therapy visits (G0151 x16).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for thirty (30) additional routine transportation 
trips. 
 
You asked the Plan to provide coverage for thirty (30) additional routine transportation trips. You say that you 
need the additional trips to go to radiation treatment every day and you have three weeks left for radiation 
treatment. The Plan denied your request. The Plan says your benefit only allows 48 one-way trips for this 
service and you have used 46 up to October 5, 2023. An additional 30 trips would exceed your benefit limit. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation up to 48 one-way trips, combined in and out-of-network each year. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to provide coverage for thirty (30) additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent transportation services provided on April 15, 
2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the non-emergent transportation services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says there was no prior authorization requested 
before the services were provided. 
 
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 non-emergent transportation services provided on 
April 15, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88361 billed for date of service June 2, 2023.  
 You asked the Plan to pay for procedure code 88361. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed number of units are not supported by the records as both provided and 
medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88361 is six (6). The MAI value for this code is 3. You billed eight (8) 
units of this code, exceeding the MUE.  
 
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 88361. Our reviewer says that the services at 
issue in this case are not supported by the medical records. Our reviewer found the documentation did show 
that 8 units of procedure code 88361 were rendered on June 2, 2023. However, only six (6) units are approved 
and the reason for the additional 2 units was not described in the provided documentation to help support them 
in this case. Therefore, the records do not sufficiently support that the additional services were reasonable and 
necessary in this case.  
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 88361 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 88361 billed for date of service June 2, 2023.