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

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service July 16, 
2022.   
You asked the Plan to pay for procedure code 88341. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
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 88341 is 13. The MAI value for this code is 3. You billed 15 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service July 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laminectomy. 
 
You asked the Plan to pre-approve a laminectomy. You say that the enrollee needs this surgery. The Plan 
denied your request. The Plan says the medical criteria for a laminectomy 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 laminectomy. 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 evidence present to show that recent trial of physical therapy for at least six months has been provided. There are more conservative measures are available. 
 
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 laminectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a laminectomy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 80307, 83789, and G0480 for date of service June 28, 
2023. 
 
You asked the Plan to pay for codes 80307, 83789, and G0480. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as 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. 
 
We find that CPT codes 80307, 83789, and G0480 are not payable as billed. Specifically, the submitted 
medical records do not contain an order that specifically lists what tests are to be performed in the panel. Based 
on this information, we decided that Medicare rules for coverage of codes 80307, 83789, and G0480 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes 80307, 83789, and G0480 for 
date of service June 28, 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 admission to the IRF is medically necessary. The 
Plan denied your request. The Plan says your medical and therapy needs could be met in a skilled nursing unit.  
 
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 You are medically stable and do not need a physical medicine and rehabilitation 
physicians supervision 3 times a week in an IRF. No acute rehabilitation nursing needs are documented. At the 
current functional mobility and activities of daily living level, you do not need intensive therapies consisting of 
at least 3 hours of therapy per day at least 5 days per week with a multidisciplinary approach in an IRF. The 
documentation did not support the necessity for admission to an IRF. The complexity of your medical, 
rehabilitation, and nursing needs was not appropriate for an acute hospital inpatient rehabilitation stay with an 
interdisciplinary approach to rehabilitative 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 pay for a manual wheelchair (K0001) provided on March 18, 2023. 
 
You asked the Plan to pay for the manual wheelchair. You say that this item was medically necessary. The Plan 
denied your request. The Plan says the enrollee was an inpatient at a SNF when this item was provided. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the manual wheelchair was used in a SNF or hospital. Therefore, we decided that the Plan 
does not have to pay for a manual wheelchair (K0001) provided on March 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87998 billed for date of service May 2, 2023.  
 You asked the Plan to pay for procedure code 87998. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
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 87998 is 13. The MAI value for this code is 3. You billed 19 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 87998 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 87998 billed for date of service May 2, 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 you are a high fall risk and you are unable to care for 
yourself. You say IRF services are medically necessary. The Plan denied your request. The Plan says the 
request for an IRF admission does not meet medical necessity.  
 
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 You do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require 15 hours per week of rehabilitative services and regular physician evaluation.  Your care 
needs can be met at a lower 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: 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 you are requesting reconsideration of the denied IRF 
admission. The Plan denied your request. The Plan says IRF care is not reasonable and 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 patients nursing, medical, and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. The documentation does not support that 
the patient would meet criteria for admission to an acute inpatient rehabilitation facility. The patient can receive 
further services at a lower 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: 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 you would like to be admitted to an IRF. You also 
say that you wish to return to being independent as quickly as possible. The Plan denied your request. The Plan 
says you do not meet requirements for an IRF admission.  
 
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 your nursing, medical, and rehabilitation needs do not require an 
acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation does not support that you 
would meet criteria for admission to an acute inpatient rehabilitation facility.  You can receive further services 
at a lower 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) provided on June 14, 
2023. 
 
You asked the Plan to pay for moderate sedation services. You say that you disagree with the denial and have 
submitted medical records for review. The Plan denied your request. The Plan says code 99152 remains 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. 
 
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 moderate sedation services. Our reviewer says that the 
service does not meet criteria for payment on this claim. Our reviewer found the documentation does not 
support code 99152. The doctor did not provide post service work after the enrollee's sedation. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that the 
Plan does not have to pay for moderate sedation services (99152) provided on June 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on 
October 12, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you disagree with the denial and 
have submitted medical records for payment reconsideration. The Plan denied your request. The Plan says the 
request is not a covered benefit per Medicare guidelines. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease 
is not eligible for reimbursement. 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided on October 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 25, 2023, billed with 
codes 81223, 81405, 81238, 81302, 81345, 81403, 81407, 81405, 81408, 81479, and 81404. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. 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 
May 25, 2023, billed with codes 81223, 81405, 81238, 81302, 81345, 81403, 81407, 81405, 81408, 81479, and 
81404.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve block. 
 
You asked the Plan to pre-approve genicular nerve block. You say that it is medically necessary. The Plan 
denied your request. The Plan says the enrollee 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 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 there is a frequency limitation: 
  For each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per 
rolling 12 months. 
This request exceeds the utilization limit and therefore, is deemed 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 genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for false tooth for bridge (D6240) for teeth 28 and 30 and white 
glass with high gold content cap for bridge (D6750) for teeth 27, 29 and 31. 
 
You asked the Plan to pay for false tooth for bridge (D6240) for teeth 28 and 30 and white glass with high gold 
content cap for bridge (D6750) for teeth 27, 29 and 31. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers false tooth for 
bridge (D6240) for teeth 28 and 30 and white glass with high gold content cap for bridge (D6750) for teeth 27, 
29 and 31 when the services are medically necessary and reasonable.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for false tooth for bridge (D6240) for teeth 28 
and 30 and white glass with high gold content cap for bridge (D6750) for teeth 27, 29 and 31. Our reviewer 
says that you do not meet the Plan's criteria for the requested services. Our physician reviewer found in this 
case there are multiple missing posterior teeth and no missing anterior teeth in the lower arch. Given the 
parameters of the coverage, there would be no meeting of the Plan criteria in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of false tooth for bridge (D6240) for teeth 28 and 30 and white glass with high 
gold content cap for bridge (D6750) for teeth 27, 29 and 31 have not been met. Therefore, we decided that the 
Plan does not have to pay for false tooth for bridge (D6240) for teeth 28 and 30 and white glass with high gold 
content cap for bridge (D6750) for teeth 27, 29 and 31.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electric stimulation therapy. 
 
You asked the Plan to pre-approve electric stimulation therapy. You say that you should not have to pay for 
this because your primary care provider referred you. The Plan denied your request. The Plan says this is not a 
covered chiropractic service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 The records show that electric stimulation therapy at issue is not manual manipulation of the spine. Therefore, 
we decided that the Plan does not have to pre-approve electric stimulation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an out-of-network provider 
on May 18, 2023. 
 
You asked the Plan to pay more for the dental services. You say that it is not easy to find a new dentist that is 
in-network. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for dental services provided by an out-of-
network provider on May 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous or minimally invasive sacroiliac joint 
fusion (27279). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan follows Medicare rules. The rules say that percutaneous minimally invasive fusion/stabilization of the 
sacroiliac joint (SIJ) for the treatment of back pain is indicated for the treatment of SIJ pain for patients with 
low back/buttock pain who meet all of the indicated criteria. 
 
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 this service. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested service. Our physician reviewer found that the 
computed tomography (CT) scan of the lumbar spine showed neural compression or other degenerative 
conditions that could cause low back or buttock pain primarily at L3-L4 level. In as much, the requirements of 
the LCD cannot be determined to have been met based on the information provided for review. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous or minimally invasive sacroiliac joint fusion (27279).