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

 
We decided that the Plan does not have to pre-approve the Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease. The cause of pain is not clear. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure (64628, 64629).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 7, 2023, to 
February 17, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
DRG billed is supported by the medical record. The Plan denied your request. The Plan says the billed 
diagnoses of A41.89 (other specified sepsis) and R65.20 (severe sepsis without septic shock) are not supported 
by the medical record. As a result, a lower DRG was paid. Although these two diagnoses were documented, 
reasonable clinical evidence within the health record is not present to clinically validate these diagnoses. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnoses of A41.89 (other specified sepsis) and 
R65.20 (severe sepsis without septic shock). 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 
inpatient hospital services at the DRG originally billed. Our reviewer says that other specified sepsis appears 
supported by the medical record, but the reported severe sepsis does not. Our physician reviewer found 
Glasgow Coma Scale (GCS) is an unreliable indicator of end-stage organ dysfunction from sepsis in this 
patient with dementia, particularly with a GCS of 14 rather than 15. The patient was maintained on her anti-
hypertensives, so it did not appear that the care team was worried about hypotension. She did have some low-
grade tachycardia and she did have Klebsiella urinary tract infection.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on February 7, 2023, to February 17, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 24, 2023, billed with 
codes 87086, 87186, 87481, 87500, 87556, 87563, 87640, 87651, 87653, 87798, and 87077. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. 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 a 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 
April 24, 2023, billed with codes 87086, 87186, 87481, 87500, 87556, 87563, 87640, 87651, 87653, 87798, 
and 87077.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81003 for date of service May 14, 2023. 
 
You asked the Plan to pay for procedure code 81003. 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 81003 is urinalysis, by dip stick or tablet reagent for 
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any 
number of these constituents; automated, without microscopy. 
 
We find that CPT code 81003 is not supported in the medical record. Specifically, the medical records 
submitted references a Clinical Laboratory Improvement Amendments (CLIA). The claim form references a 
different CLIA. Due to this discrepancy, the services rendered are unable to be verified. Based on this 
information, we decided that Medicare rules for coverage of procedure code 81003 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 81003 for date of service May 14, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous (IV) solution (J3490), Ringers lactate 
infusion (J7120), and facility services for dental rehabilitation procedure(s) (G0330) provided on June 30, 
2023. 
 
You asked the Plan to pay for the IV solution, Ringers lactate infusion, and facility services. You say that you 
would like this claim to be reconsidered for medical necessity. The Plan denied your request. The Plan says the 
medical record shows that treatment was done on an outpatient basis (not inpatient) and that the services 
provided (cleaning of the teeth and filling of cavities) were not covered by Medicare. 
 
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 IV 
solution, Ringers lactate infusion, and facility services 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 the IV solution, Ringers lactate infusion, and 
facility services. Our reviewer says that this request is not medically reasonable and necessary. Our physician 
reviewer found the clinical note states that enrollee is developmentally delayed and nonverbal, has a seizure 
disorder which necessitated the need to have their dental treatment in the operating room. The procedures that 
were completed were: full mouth dental rehabilitation with radiographs and fillings x3, exam under anesthesia, 
and a dental cleaning. Our reviewer also found that the medical history was lacking, the medical conditions 
documented were general. The term developmental delay is an expansive term and can range from mild to 
severe. Many people with developmental delays and those who have a seizure disorder are able to receive 
dental services outside of a hospital setting. Our physician reviewer found that due to the lack of information 
regarding the enrollees medical conditions, the procedures in question are not medically reasonable. 
 
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 IV solution, Ringers lactate infusion, and facility services have not been 
met. Therefore, we decided that the Plan does not have to pay for the intravenous (IV) solution (J3490), 
Ringers lactate infusion (J7120), and facility services for dental rehabilitation procedure(s) (G0330) provided 
on June 30, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for pathology services (88302) provided on May 24, 2023. 
 
You asked the Plan to pay for pathology services. You say that this test was necessary and was reported 
appropriately, as no diagnosis has been established for this encounter. The Plan denied your request. The Plan 
says that this claim was not submitted with an appropriate primary diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that for outpatient encounters for diagnostic tests that have been interpreted by a physician, and the 
final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the 
interpretation. The rules also say that Medicare health plans must make reasonable and diligent efforts to gather 
and forward to the IRE information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, although the records indicate that this was a diagnostic service 
which involved physician interpretation, the records do not include documentation of a definitive diagnosis. 
Sometimes, additional diagnostic tests are required to find a definitive diagnosis. The records indicate that this 
test was performed with abnormal findings but no definitive diagnosis. In this case, it would be appropriate to 
use an R00-R99 code, as there is no more specific code which would be known at this time. Therefore, we 
decided that the Plan has to pay for pathology services (88302) provided on May 24, 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 pre-approve an admission to a SNF to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve admission to a SNF. You say that you frequently use a sister facility but 
there is no room available for you there. You say you will need to stay at the requested SNF until space is 
available.  The Plan denied your request. The Plan says you must receive your care from a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an admission to a SNF to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274 x2) 
provided on July 6, 2023. 
 
You asked the Plan to pay for the two bitewings - four radiographic images. You say that this was your first 
visit to this dentist and the images were required to give him information for the impending course of 
treatment. The Plan denied your request. The Plan says your benefit for the requested bitewings - four 
radiographic images has already been exhausted. The Plan also says that the Plan provided payment for a total 
of 4 x-rays as an extended courtesy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 services was exhausted on date of service July 6, 2023. Therefore, we 
decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274 x2) provided on 
July 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87502, 87581, 87634, 87651, 87798, 
U0003, and U0005 for date of service February 1, 2023. 
 
You asked the Plan to pay for procedure codes 87502, 87581, 87634, 87651, 87798, U0003, and U0005. 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. 
 
We find that CPT codes 87502, 87581, 87634, 87651, 87798, U0003, and U0005 are not supported in the 
medical record. Specifically, the documentation submitted did not include documentation of an order that 
specifically lists what test(s) were to be performed in the custom panel provided. Without this documentation, 
these codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of procedure codes 87502, 87581, 87634, 87651, 87798, U0003, and U0005 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87502, 87581, 87634, 87651, 87798, U0003, 
and U0005 for date of service February 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bilateral L4-L5 and L5-S1 medial branch blocks provided on 
August 22, 2022. 
 
You asked the Plan to pay for bilateral L4-L5 and L5-S1 medial branch blocks. You say that the injections 
performed were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says 
the procedure performed does not meet the criteria 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 pay for bilateral L4-L5 
and L5-S1 medial branch blocks. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found that the medical records do not 
show other causes for back pain have been ruled out. There is no imaging other than procedural imaging which 
may show scoliosis. The review has determined that the enrollee does not meet the LCD criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral L4-L5 and L5-S1 medial branch blocks have not been met. Therefore, 
we decided that the Plan does not have to pay for bilateral L4-L5 and L5-S1 medial branch blocks provided on 
August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services billed with code 81479 for date of 
service June 9, 2023. 
 
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 for date of service June 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for date of service May 1, 2023. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 We looked at the file and the rules. The claim was billed with 22, an outpatient hospital facility place of service 
code. The medical records show that the enrollee was being discharged from inpatient care. 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 99239 billed for date of service May 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 13, 2023, billed with 
codes 87640, 87900, 87481, 87500, 87798 x13, 87799 (59) and 87652. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was ordered based upon the 
treating physicians clinical training and medical necessity. 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. The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and 
sensitivity. 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 
June 13, 2023, billed with codes 87640, 87900, 87481, 87500, 87798 x13, 87799 (59) and 87652.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 provided on March 31, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for procedure code 87798. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for procedure code 87798 provided on March 31, 
2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical traction unit (E0849). 
 
You asked the Plan to pay for a cervical traction unit. You say that please review and reprocess as the doctor 
states this was ordered to help the enrollee with mobility issues.  The Plan denied your request. The Plan says 
the diagnosis on the records does not match the diagnosis on the prescription. 
 
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 a cervical traction unit. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's prescribing doctor documented diagnosis of cervicalgia and injury of 
nerve root of cervical spine. A request was made for a cervical traction unit (E0849) to use to restrict mobility 
and provide support, according to the documentation. The diagnosis and reasoning did not match as cervical 
traction is not used to restrict mobility or provide support for the cervical spine. Also, the provided 
documentation did not show the enrollee reporting of neck pain or dysfunction, nor was there a physical 
examination describing cervical dysfunction to help support this request. Therefore, the cervical traction unit is 
not medically necessary based on the provided documentation.  
 
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 cervical traction unit have not been met. Therefore, we decided that the Plan 
does not have to pay for a cervical traction unit (E0849).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
for your medical appointments. The Plan denied your request. The Plan says you have utilized the maximum 
number of transportation trips allowed per year. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips (A0120).