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

 
We decided that the Plan does not have to pay for medical nutrition therapy services provided on February 9, 
2023. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you disagree with the Plan's 
denial The Plan denied your request. The Plan says these services are only covered for diabetes and renal 
disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for medical nutrition therapy services provided on February 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable to be discharged to 
LTACH level of care. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee's needs can be met in the current hospital setting.  
 
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 that the enrollee is unstable and requires short-term additional acute care hospital 
services that can be safely provided at the current facility until they are more appropriate and 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this would help with the enrollee's back 
pain. The Plan denied your request. The Plan says this procedure is experimental. 
 
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 an 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 magnetic resonance imaging (MRI) show multiple areas of foraminal stenosis. 
The cause of back 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service August 25, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the claim for this 
molecular pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 the lab testing billed for date of 
service August 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81479 provided on 
October 27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services billed 
with code 81479 provided on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on May 17, 2022, to 
May 19, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment per day, per stay: Days 1-7 for inpatient hospital stay. Includes inpatient acute, inpatient 
rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care 
starts the day you are formally admitted to the hospital with a doctors order. The day before you are 
discharged is your last inpatient day. The plan covers an unlimited number of days for an inpatient hospital 
stay. There were two days. 2 x $200 = $400. Therefore, results in the total cost sharing amount of $400. You have been asked to pay a $200 copayment per day for inpatient hospital stay. This item/service falls within 
the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. 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 waive the copayment for inpatient 
hospital stay on May 17, 2022, to May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SPRINT PNS system. 
 
You asked the Plan to pre-approve the SPRINT PNS system. You say that the services are medically necessary. 
The Plan denied your request. The Plan says this is considered experimental. 
 
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 SPRINT PNS system. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered experimental. 
 
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 SPRINT PNS system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the SPRINT PNS system.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or 
tissue-based product (Via Disc NP). 
 
You asked the Plan to pre-approve Via Disc NP. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested services are 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 Via Disc NP. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of chronic low back pain. The enrollee describes three out of 10 low 
back pain that worsens with activities. An MRI of lumbar spine on April 24, 2023, revealed multilevel chronic 
compression fractures throughout the visualized lower thoracic and lumbar spine, with interval increase in vertebral body height loss of L3; moderate to severe symmetric paraspinal muscle atrophy, increased in the 
interval; disc degeneration and facet arthritis contribute to increased canal stenosis at L2-L3 and L3-L4, with 
up to moderate severe canal stenosis; moderate left foraminal stenosis at L2-L3. The enrollee has been treated 
with Meloxicam and Gabapentin. There is little evidence in the medical literature to suggest that this is an 
appropriate procedure for the enrollee's back pain. It is not an accepted standard of medical practice for the 
diagnosis or treatment of back pain. The requested injection of allograft (in this case, VIA Disc NP) into the 
intervertebral disc for the treatment of degenerative disc disease, is considered experimental and 
investigational. VIA Disc is considered investigational and not medically necessary for the treatment of 
degenerative disc disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Via Disc NP have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product (Via Disc NP).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for date of service December 
14, 2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the code. The Plan 
denied your request. The Plan says the billed code 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 99221 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A 
detailed or comprehensive examination; and medical decision making that is straightforward or of low 
complexity.  We find that CPT code 99221 is not supported in the medical record. Specifically, the records provided do not 
include a detailed or comprehensive history. 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 code 99221 billed for date of service December 14, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on August 10, 
2022. 
 
You asked the Plan to pay for the emergency room services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the records do not support the code 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 99285 is an emergency department evaluation and 
management code requiring a comprehensive history, a comprehensive examination and medical decision 
making of high complexity. 
 
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 emergency room services. Our reviewer says that the 
documentation does not support the billed service. Our reviewer found the records do not show medical 
decision making of high complexity. 
 
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 emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99285) provided on August 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0657). 
 
You asked the Plan to pre-approve a pneumatic compression device . You say that the items are medically 
necessary. The Plan denied your request. The Plan says  there is no documentation of lymphedema of the chest 
or trunk. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652, E0657).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NuShield skin substitute (Q4160). 
 
You asked the Plan to pre-approve NuShield skin substitute. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not show that the wound has failed to respond to 4 weeks of 
standard wound care. 
 
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 NuShield skin substitute. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that you have venous stasis ulcers. The record indicates that the 
ulcer has become smaller with standard wound care and does not support the failure of standard wound 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 NuShield skin substitute have not been met. Therefore, we decided that the Plan 
does not have to pre-approve NuShield skin substitute (Q4160).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
tooth #30 (D6057), and abutment supported porcelain/ceramic crown tooth #30 (D6058). 
 
You asked the Plan to pre-approve the dental services represented by codes D6057 and D6058. You say that 
you do not agree with the denial as you had these denied posts since 2022. You also say that you cannot pay for 
them. The Plan denied your request. The Plan says your benefit for the requested services 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 February 16, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment  includes 
placement tooth #30 (D6057), and abutment supported porcelain/ceramic crown tooth #30 (D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical cancer screening test (G0101) provided on 
January 16, 2023. 
 
You asked the Plan to pay for the screening test. You say that you thought you should be proactive in your 
healthcare. The Plan denied your request. The Plan says that the benefit for this service has been exhausted. 
 The Plan must follow Medicare rules. Medicare rules say that a screening pap smear and related medically 
necessary services provided to a woman for the early detection of cervical cancer and pelvic examination are 
covered under Medicare Part B when ordered by a physician when she has not had such a test during the 
preceding two years or is a woman of childbearing age. 
 
We looked at the file and Medicare rules. The Evidence of Coverage clearly states that pap tests and pelvic 
exams are covered once every 24 months. Based on this information, we decided that Medicare rules for 
coverage of the screening test have not been met. The record shows that the Plan paid for this service within the 
last 24 months. Therefore, we decided that the Plan does not have to pay for the cervical cancer screening test 
(G0101) provided on January 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services (99221) provided on February 18, 2023. 
 
You asked the Plan to pay for the inpatient services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with a valid place of service. 
 
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 code 99221 is not supported in the medical record. Specifically, an inpatient code was billed 
with an outpatient place of service (23- Emergency Room). Based on this information, we decided that 
Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient services (99221) provided on February 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service April 5, 
2022. 
 You asked the Plan to pay for procedure code 99214. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says payment for code 99214 is bundled into payment for code G0439. 
 
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, we have confirmed that code 99214 
is a column II code to column I code G0439. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99214 billed for date of service April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that this device is not medically necessary. Our physician reviewer found the documentation does not 
contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee 
could be treated with a BiPAP machine. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service December 
15, 2022.  
 
You asked the Plan to pay for procedure code 76942. 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 76942 is 1. The MAI value for this code is 3. You billed 2 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 76942 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76942 billed for date of service December 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 63045-59 billed for date of service March 13, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the code. The Plan 
denied your request. The Plan says the billed code and modifier are not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   We looked at the file and the rules. The medical records do not show that the service billed with the -59 
modifier was a distinct procedural service, or was performed on a different site that is not ordinarily 
encountered on the same day. 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 code 63045-59 billed for 
date of service March 13, 2023.