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

 
We decided that the Plan does not have to pay for the implant maintenance procedure (D6080) provided on 
June 6, 2023.  
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service provided is not covered under the 
supplemental dental policy.  
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant 
maintenance procedure (D6080) provided on June 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pitavastatin. 
 
You asked the Plan to pre-approve Pitavastatin. You say that the enrollee needs for treatment. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pitavastatin.   
Benefits for Pitavastatin may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aciphex. 
 
You asked the Plan to pre-approve the medication. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Aciphex.  Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Discern Alzheimer's Disease (AD) Report (0206U, 
0207U) provided November 2, 2022. 
 
You asked the Plan to pay for the laboratory testing. You say that you strongly believe that these were 
medically necessary and should be reconsidered for payment. The Plan denied your request. The Plan says the 
clinical value and effectiveness of the Discern Alzheimer's Disease (AD) Report in the setting of dementia, and 
Alzheimer's Disease have not been demonstrated in the peer-reviewed literature. 
 
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 pay for the laboratory testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation that the Discern Alzheimer's 
Disease (AD) Report via skin biopsy at issue in this case meets all Medicare criteria for medically reasonable 
and necessary and safe and effective for the enrollee The provided medical records and review of the current 
peer-reviewed medical literature do not document that use of the Discern Alzheimer's Disease (AD) Report has 
been shown in controlled studies in a CMS-approved journal to result in sustained long term health benefits in 
the Medicare population with senile dementia as described in this clinical scenario. 
 
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 laboratory testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Discern Alzheimer's Disease (AD) Report (0206U, 0207U) provided November 2, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
October 6, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service March 16, 2022.  
  
 
Specifically, the Plans contract states that a panoramic radiographic image or related service is covered once 
every three years. You previously received an intraoral-comprehensive series of radiographic images (D0210) 
on March 16, 2022, less than three years prior, which was paid for by the Plan. The Plans contract states that 
this is a related service to the service at issue. Therefore, you have exhausted the allowable benefit for the 
service provided in this case. Therefore, we decided that the Plan does not have to pay for the panoramic 
radiographic image (D0330) provided on October 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 23, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on June 23, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the peripheral nerve block injection described by code 64447 billed for 
date of service April 3, 2023. 
 
You asked the Plan to pay for 64447. You say that 64447 should be paid as billed because it is supported in the 
documentation and modifier -59 was appended. The Plan denied your request. The Plan says that 64447 is 
denied because payment for this service is bundled into payment for 01402. 
 
The Plan must follow Medicare rules. Medicare rules say that a peripheral nerve block may be separately 
reported on the same day as an anesthesia code 0XXXX if the mode of intraoperative anesthesia is 
subarachnoid injection, the adequacy of the intraoperative anesthesia is not dependent on the nerve block, it is 
administered for postoperative pain management at the request of the surgeon, and modifier -59 is appended. 
 
We looked at the file and Medicare rules. In this case, we confirmed that the peripheral nerve block injection 
described by procedure code 64447 was performed on the same date as anesthesia code 01402. Records 
indicate the enrollee had a right total knee arthroplasty for which the primary mode of anesthesia was spinal 
(subarachnoid injection). Records clearly indicate that 64447 was intended for and administered for 
postoperative pain management at the surgeon's request. Per Medicare rules, if the mode of intraoperative 
anesthesia is subarachnoid injection, as it is in this case, a peripheral nerve block for postoperative pain 
management performed at the request of the surgeon may be reported separately with modifier -59 appended. 
We have confirmed that 64447 was billed with modifier -59. Separate reporting of a nerve block injection for 
postoperative pain management does not necessarily require that the nerve block must be administered 
postoperatively. Per Medicare rules, it may be administered preoperatively, intraoperatively, or postoperatively. 
Based on this information, we decided that Medicare rules for coverage of 64447 have been met. Therefore, we decided that the Plan has to pay for the peripheral nerve block injection described by code 64447 billed for date 
of service April 3, 2023.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services billed with code 92507-GN-KX for date of 
service March 3, 2023. 
 
You asked the Plan to pay for the therapy services. You say that the Plan has not given you a proper 
explanation as to why the payment for this service was taken back. The Plan denied your request. The Plan says 
the payment for these services is included in the SNF payment. 
 
The Plan must follow Medicare rules. Medicare rules say that physical therapy, occupational therapy, and/or 
speech-language pathology services furnished to a skilled nursing facility (SNF) resident must be billed by the 
SNF itself. This is known as consolidated billing, and no separate payment is made for these services. 
 
The services in dispute in this appeal are speech therapy services, and the enrollee was a SNF resident at the 
time of these services.  As a result, no separate payment can be made for the services in dispute, as they are part of the SNF's consolidated billing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay 
for therapy services billed with code 92507-GN-KX for date of service March 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint denervation (64636, 64635). 
 
You asked the Plan to pre-approve facet joint denervation. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve facet joint denervation. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found facet blocks after Anterior 
Interbody fusion is specifically excluded from coverage. Therefore, the request 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 facet joint denervation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint denervation (64636, 64635).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the peripheral nerve block injections described by codes 64447 and 
64450 performed on date of service August 10, 2023. 
 
You asked the Plan to pay for 64447 and 64450. You say that 64447 and 64450 should be paid as billed 
because they are supported in the documentation and modifier -59 was appended to both codes. The Plan 
denied your request. The Plan says that 64447 and 64450 are denied because payment for these services is 
bundled into payment for procedure code 01402. 
 
The Plan must follow Medicare rules. Medicare rules say that a peripheral nerve block may be separately 
reported on the same day as an anesthesia code 0XXXX if the mode of interoperative anesthesia is 
subarachnoid injection, the adequacy of the intraoperative anesthesia is not dependent on the nerve block, it is 
administered for postoperative pain management at the request of the surgeon, and modifier -59 is appended. 
 
We looked at the file and Medicare rules. In this case, we confirmed that the peripheral nerve block injections 
described by procedure codes 64447 and 64450 were performed on the same date as anesthesia code 01402. 
Records indicate the enrollee had a right total knee arthroplasty for which the primary mode of anesthesia was 
spinal (subarachnoid injection). Records clearly indicate that both 64447 and 64450 were intended for and 
administered for postoperative pain management at the surgeon's request. Per Medicare rules, if the mode of 
intraoperative anesthesia is subarachnoid injection, as it is in this case, a peripheral nerve block for 
postoperative pain management performed at the request of the surgeon may be reported separately with 
modifier -59 appended. We have confirmed that both 64447 and 64450 were billed with modifier -59. Separate 
reporting of a nerve block for postoperative pain management does not necessarily require that the nerve block 
must be administered postoperatively. Per Medicare rules, it may be administered preoperatively, intraoperatively, or postoperatively. Based on this information, we decided that Medicare rules for coverage of 
64447 and 64450 have been met. Therefore, we decided that the Plan has to pay for the peripheral nerve block 
injections described by codes 64447 and 64450 performed on date of service August 10, 2023.  
 
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: Favorable

 
We decided that the Plan has to pay for the peripheral nerve block injection described by code 64415-59 billed 
for date of service September 7, 2023. 
 
You asked the Plan to pay for 64415-59. You say that 64415-59 should be paid as billed because it is supported 
in the medical record. The Plan denied your request. The Plan says that 64415-59 is denied because payment 
for this service is bundled into payment for procedure code 01638. 
 
The Plan must follow Medicare rules. Medicare rules say that a peripheral nerve block may be separately 
reported on the same day as an anesthesia code 0XXXX if the mode of interoperative anesthesia is general, the 
adequacy of the intraoperative anesthesia is not dependent on the nerve block, it is administered for 
postoperative pain management at the request of the surgeon, and modifier -59 is appended. 
 
We looked at the file and Medicare rules. In this case, we confirmed that the peripheral nerve block injection 
described by code 64415-59 was billed on the same date as anesthesia code 01638. Records indicate that the 
enrollee had a left reverse total shoulder arthroplasty and general anesthesia was the primary anesthesia used. 
The records clearly indicate that the peripheral nerve block injection was intended for and administered for 
postoperative pain management at the request of the surgeon. Per Medicare rules, if the mode of intraoperative 
anesthesia is general, as it is in this case, a peripheral nerve block for postoperative pain management 
performed at the request of the surgeon may be reported separately with modifier -59 appended. Separate 
reporting of a nerve block injection for postoperative pain management does not necessarily require that the 
nerve block injection must be administered postoperatively. Per Medicare rules, it may be administered 
preoperatively, intraoperatively, or postoperatively. Based on this information, we decided that Medicare rules for coverage of 64415-59 have been met. Therefore, we decided that the Plan has to pay for the peripheral 
nerve block injection described by code 64415-59 billed for date of service September 7, 2023.  
 
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: 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 were independent and active before coming to 
the hospital and wish to return to being independent. The Plan denied your request. The Plan says the inpatient 
rehabilitation facility (IRF) services you are requesting do not meet the requirements for approval.  
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. The enrollee 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 enrollee 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: 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 a home ventilator. You say that without ventilator therapy, this enrollee is at 
high risk for hospital readmission and potentially life-threatening exacerbation. The Plan denied your request. 
The Plan says the enrollee does not meet criteria for approval of the requested ventilator. 
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the records in this case document a 
diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records 
document that the home ventilator is being requested for use in an average volume assured pressure support 
(AVAPS) mode which is a modality that could be provided by a bilevel positive airway pressure (BiPAP) 
device with AVAPS and a back-up rate. Provided records do not document trial and failure of a BiPAP device 
with AVAPS and a back-up rate. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 the enrollee requires an IRF admission to return to 
prior level of function. The Plan denied your request. The Plan says the enrollee's needs can be met at an 
alternate 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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical problems 
are stable and there are no complex nursing or rehabilitation needs. You do 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 you 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.