Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service 
December 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that the specimens must be processed without delay. 
The Plan denied your request. The Plan says a complete description of the codes was not provided. 
 
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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism 
 
 We find that CPT codes 83520 and 87798 are not supported in the medical record. The records show that a 
comprehensive panel test and stool tests were provided. The records do not include specifics about the tests that 
are described as not otherwise specified  Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 83520 and 87798 billed for date of service December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gym membership provided on January 1, 2023. 
 
You asked the Plan to pay for a gym membership. You say that you want to know why the request for a fitness 
reimbursement was denied. The Plan denied your request. The Plan says based on a review of the information 
available, it was determined that this facility is not a qualified health club or fitness facility. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan rules say that the 
Plan reimburses you up to $350 per calendar year towards your cost for membership in a qualified health club 
or fitness facility during the calendar year. 
 The Plans rules for coverage of gym benefits have not been met because this is not a qualified health club or 
fitness facility. Therefore, we decided that the Plan does not have to pay for a gym membership provided on 
January 1, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97116, 97530, and 97750 billed for date of 
service April 13, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the validity of the services cannot be verified. 
 
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 97116 is therapeutic procedure, 1 or more areas, each 15 
minutes; gait training (includes stair climbing). The definition of code 97530 is therapeutic activities, direct 
(one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
The definition of code 97750 is physical performance test or measurement (e.g., musculoskeletal, functional 
capacity), with written report, each 15 minutes. We find that CPT codes 97116, 97530, and 97750 are not supported in the medical record. The records 
provided do not document the time spent on each individual procedure code. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 97116, 97530, and 97750 billed for date of service April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns - porcelain/ceramic (D2740) provided on April 7, 
2023. 
 
You asked the Plan to pay for the crowns. You say that you do not agree with the denial for the dental services. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for crowns - porcelain/ceramic (D2740) provided on April 7, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental/investigational at this time. This procedure 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 the Intracept procedure. 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 magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or stenosis. The cause of pain is not clear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a lumbar laminectomy (63047). 
 
You asked the Plan to pre-approve a lumbar laminectomy. You say that this is medically necessary. The Plan 
denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a lumbar laminectomy. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee presented with subjective complaints of worsening pain and noted 
numbness and symptoms of neurogenic claudication. There is documentation of a trial and failure of 
conservative measures including medications, physical therapy/home exercises, chiropractic treatment, as well 
as lumbar epidural steroid injections at the bilateral L4 and L5 without significant sustained relief.  
The provider is requesting a lumbar laminectomy at multiple levels (L1-2, L2-3, L3-4, and L4-5). The 
combination of the subjective and objective (clinical and imaging) findings as well as the provided lumbar 
magnetic resonance imaging, computed tomography, and radiographic imaging does support surgical 
intervention at all of the requested levels. Large-scale, long-term references showing the safety and efficacy of 
the requested surgery (in this setting of severely symptomatic spinal stenosis, radiculopathy, and myelopathy) 
are supportive. 
 
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 laminectomy have been met. Therefore, we decided that the Plan has 
to pre-approve a lumbar laminectomy (63047).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on May 31, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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 your benefit for the requested item or service was exhausted on date of service November 4, 2020. 
Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (D5110).
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 admission is medically necessary. The Plan 
denied your request. The Plan says the patient does not meet the requirements. Services needed may be 
provided safely in a lower level of care. 
 
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 patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for cervical spine surgery. Their medical problems are stable and there are no complex nursing or 
rehabilitation needs.  
 
The patient 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 
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 this 
patient 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 the nursing facility care provided on April 18, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service was not authorized. 
 
 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 nursing facility care provided on April 18, 
2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950) and intraoral - periapical first 
radiographic image (D0220). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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 your benefit for intraoral - periapical first radiographic image was exhausted on date of service April 13, 
2023. Therefore, we decided that the Plan does not have to pre-approve core buildup (D2950) and intraoral - periapical first radiographic image (D0220).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 97016, J3420, J3411, J3415, and J1955 
billed for date of service September 22, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the medical records do not support the services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The CPT Code Manual definition of code 97016 is application of a modality to 1 or more areas; vasopneumatic 
devices. We looked at the file and the rules. The records show that the enrollee was being treated for pain 
numbness and tingling. Vasopneumatic therapy is indicated for edema.  
 
The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The 
rules require that any compounded drug be billed using the not otherwise classified code J7999. As this 
compounded drug was not billed properly, payment cannot be made. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 97016, J3420, J3411, J3415, and J1955 billed for date of service 
September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 billed for 
date of service February 8, 2023. 
 
You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the billed codes are 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. 
 
The file shows that outpatient intravenous insulin therapy was provided. We find that CPT codes 96365, 96366, 
and J1817 are not supported. There are more accurate codes available that describe the services provided. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. We find that CPT code 96521 is not supported in the records. The records do not document the refilling and 
maintenance of a pump. Based on this information, we decided that the Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, 
and J1817 billed for date of service February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the service is medically necessary.  
The Plan denied your request. The Plan says your request does not meet the requirements for approval.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the cause of pain is unclear. There is no magnetic resonance imaging (MRI) showing 
only modic changes without facet degenerative joint disease or foraminal stenosis. Therefore, Medicare criteria 
have not been met. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (the Intracept procedure).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper denture (D5110) and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve complete upper denture and partial lower denture. You say that this should 
be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
complete upper denture (D5110) and partial lower denture (D5214).
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 will benefit from an 
admission to a long-term acute care hospital to regain maximum prior level of function as well as continue with 
the multidisciplinary approach to care. The Plan denied your request. The Plan says the enrollee's records do 
not show your condition will require an average 25-day length of stay in the LTACH. The Plan says that the 
services needed may be provided safely in a lower 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 there are no services available at the LTACH that the enrollee requires that are not available at the current health care setting being offered by the health plan. 
 
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.