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

 
We decided that the Plan does not have to pre-approve paravertebral facet joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve RFA. You say that you are appealing the denial. The Plan denied your 
request. The Plan says that the enrollee does not meet the LCD criteria. 
 
The Plan follows Medicare rules. Medicare rules say that paravertebral facet joint RFA may be covered under 
certain circumstances. 
 
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 RFA. Our reviewer says that the request 
is deemed not medically reasonable and necessary. Our physician reviewer found that the LCD requirement is 
80% pain relief from 2 sets of diagnostic medial branch blocks. This was not achieved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve paravertebral facet joint radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital stay and hospital 
observation on May 17, 2023, to May 29, 2023.  
 
You asked the Plan to waive the copayments for the inpatient hospital stay and hospital observation. You say 
that you should be liable for one copay for the surgery since the other services were a result from the procedure 
performed. 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 $335 
copayment per day for days 1-5 for inpatient hospital care. You must pay a $295 for observation services.  
 
You have been asked to pay a $335 copayment for the inpatient hospital stay and $295 copayment for each 
hospital observation. This item/service falls within the inpatient hospital care and outpatient hospital 
observation 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. The total you owe is $925 ($295 copayment x 2 visits = $590 [$590 + $335]). Therefore, we decided that 
the Plan does not have to waive the copayments for the inpatient hospital stay and hospital observation on May 
17, 2023, to May 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the electrocardiogram, routine ECG with 
at least 12 leads (93005) and a walker (E0143) provided March 1, 2023, to March 17, 2023. 
 
You asked the Plan to waive the coinsurance for the walker and diagnostic service. You say that you were told 
that these charges should not have been filed and you would like to be refunded. 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 20% 
coinsurance for all other Medicare covered DME items and $25 copay for each Medicare covered diagnostic 
procedure and test.  
 You have been asked to pay $39.46 ($14.46 coinsurance + $25) for the walker and diagnostic service. These 
item/services fall within the Durable medical equipment (DME) and related supplies and Outpatient diagnostic 
tests and therapeutic services and supplies benefit categories. 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 coinsurance 
for the electrocardiogram, routine ECG with at least 12 leads (93005) and a walker (E0143) provided March 1, 
2023, to March 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) and core buildup (D2950) for tooth 
number 11. 
 
You asked the Plan to pre-approve the dental services. You say that your gum is receding, but you are not in 
any discomfort and provider is recommending these procedures for your tooth. The Plan denied your request. 
The Plan says the criteria for coverage have not been met. 
 
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 the dental 
services when the services are medically necessary and reasonable. The Plans rule for coverage states dental 
services will only be covered if there is a good long-term prognosis. 
 
 
  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 dental services. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that the documentation indicates that 
tooth number 11 does not exhibit significant coronal breakdown due to caries or fracture to warrant a core 
buildup (D2950) and crown restoration (D2751). There does appear to be abfraction which can be restored with 
conventional filling material. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2751) and core buildup (D2950) for tooth number 11.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 3, 2023, billed with 
procedure codes 99292-25 and 36556. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 codes 99292-25 and 36556 is critical care, evaluation and 
management of the critically ill or critically injured patient; each additional 30 minutes (List separately in 
addition to code for primary service), and insertion of non-tunneled centrally inserted central venous catheter; 
age 5 years or older. 
 
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 practitioner services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found that the documentation does not support 
99292-25. The supported critical care time for 99292 is 75-104 minutes, and the documented critical time is 35 
minutes. For code 36556, the procedure was performed on the common femoral vein, which per guidelines 
does not support. 
 
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 practitioner services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for practitioner services provided on April 3, 2023, billed with procedure codes 
99292-25 and 36556.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two units each of procedure codes 64415 and 76942 rendered 
on June 29, 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 while the documentation does not support that excess units were provided, they have not given 
any specific rationale as required by the policy as to why additional units were needed to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 64415: 
 
Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed 
 
CPT 76942: 
 
Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 
supervision and interpretation 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, a right interscalene 
(brachial plexus) block for postoperative pain control (CPT 64415), which should be billed on one line. The 
records do not support that the additional units were actually rendered in this case. The records, also, do not 
support that the additional services were reasonable or necessary in this case. 
 
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 two units each of procedure codes 64415 and 76942 rendered on June 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 26, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is 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 find that payment for CPT code 99223 is not supported in the medical record. Specifically, the records 
provided do not specify the date of service. The records only reference result dates and electronic signature 
dates, which do not qualify as the date of service. As such, the requested services cannot be verified for the 
billed date of service. 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 the services provided on April 
26, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 19, 
2023, to May 9, 2023. 
 You asked the Plan to pay for SNF care. You said that admission into a skilled nursing facility was medically 
necessary. The Plan denied your request. The Plan said admission into a skilled nursing facility was not 
reasonable or necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs 
that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 
not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from April 19, 2023, to May 9, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fragile X (81243). 
 
You asked the Plan to pre-approve Fragile X. 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 Fragile X. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case there is no clinical rationale for the requested test. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fragile X have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fragile X (81243).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81226, 81241, 81240, 81401, 
and 81479 for date of service April 27, 2023. 
 
You asked the Plan to pay for the laboratory services coded 81226, 81241, 81240, 81401, and 81479. 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. 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 laboratory services 
coded 81226, 81241, 81240, 81401, and 81479 have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services coded 81226, 81241, 81240, 81401, and 81479 for date of service April 
27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and brief emotional/behavioral assessment 
provided on June 2, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the outpatient services. You say that you are a network provider. You also say 
that this should be reprocessed and paid. The Plan denied your request. The Plan says prior authorization was 
not obtained. 
 
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. 
 
You are 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 office visit and brief emotional/behavioral assessment provided on June 2, 
2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0483 for date of service April 13, 2023. 
 
You asked the Plan to pay for code G0483. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed 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. 
 
 In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the submitted medical 
records did not include a complete order that specifically lists all the tests that were to be performed in the 
custom panel. This means the code billed is not supported. Based on this information, we decided that 
Medicare rules for coverage of code G0483 have not been met. Therefore, we decided that the Plan does not 
have to pay for code G0483 for date of service April 13, 2023.
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 12, 
2023.  
 
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 16 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 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27335 billed for date of service April 26, 
2023. 
 You asked the Plan to pay for procedure code 27335. You say that this service was necessary and was reported 
appropriately for additional payment. The Plan denied your request. The Plan says this code is not supported 
for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 27335 is a column II code to column I code 27447; however, 27335 
was billed with a modifier.  
 
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 procedure code 27335. Our reviewer says that this code is 
not supported for separate billing or payment. Our reviewer found the documentation provided does not 
support that code 27335 was performed above and beyond the requirement for procedure code 27447. The 
operation to perform 27335 is included in the overall procedure with 27447. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 27335 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 27335 billed for date of service April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit provided on May 02, 2023. 
 
You asked the Plan to pay for an office or other outpatient visit. You say that the services were medically 
necessary. 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 an office or other 
outpatient visit provided on May 02, 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 the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested service is 
experimental/investigational. 
 
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 service is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve block is experimental for knee pain. 
 
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).