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

 
We decided that the Plan has to pay for the peripheral nerve block injection described by code 64415 billed on 
date of service April 25, 2023. 
 
You asked the Plan to pay for 64415. You say that 64415 should be paid as billed because it is supported in the 
documentation and was billed with modifier -59. The Plan denied your request. The Plan says that 64415 is 
denied because records indicate this service was performed preoperatively. 
 
The Plan must follow Medicare rules. Medicare rules say that a peripheral nerve block injection for 
postoperative pain management can be reported separately on the same date of service as an anesthesia 
0XXXX code with modifier -59 or -XU appended to indicate it was administered for postoperative pain 
management.  
 
We looked at the file and Medicare rules. In this case, we confirmed that 64415 was reported on the same day 
as anesthesia code 01610. We confirmed 64415 was billed with modifier -59. The records clearly document in 
several places that the nerve block injection coded as 64415 was intended for postoperative pain management. 
There is no evidence in the record that 64415 was performed before or during the surgery performed on the 
same date. Based on this information, we decided that Medicare rules for coverage of 64415 have been met. 
Therefore, we decided that the Plan has to pay for the peripheral nerve block injection described by code 64415 
billed on date of service April 25, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 06, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was 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 the laboratory services 
provided on April 06, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatments. The Plan denied your request. The Plan says there is not enough evidence that this will 
be an effective treatment. 
 
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 Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found this procedure is experimental as additional research is needed. Therefore, the 
reviewer found that the requested Intracept procedure is not medically 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure).
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 now medically stable, and 
their medical complexity requires LTACH level of care. You say that discharge to a lower level of care would 
likely result in recurrent hospitalization, mobility, and potential mortality. The Plan denied your request. The 
Plan says an LTACH admission is not medically necessary. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the current 
acute care 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 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 a breast reduction. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of breast hypertrophy, or symptoms from breast hypertrophy 
that this surgery aims to treat. 
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has breast ptosis secondary to massive weight loss 
after bariatric surgery. The record provided does not establish that the requested service is to restore or improve 
function and correct any deformities or abnormal structures of the body that have been caused by congenital 
defects, developmental abnormalities, trauma, infection, tumors or disease. Furthermore, the record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. The elements of the coverage criteria are not satisfied. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a breast reduction.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0364), a pulp vitality test 
(D0460), and a limited oral evaluation (D0140), provided on July 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these 
services. The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 D0140 was exhausted on date of service July 18, 2023. D0360 and D0364 are not covered dental 
benefits. Therefore, we decided that the Plan does not have to pay for a cone beam CT capture (D0364), a pulp 
vitality test (D0460), and a limited oral evaluation (D0140), provided on July 19, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on June 14, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was medically necessary and should be paid. 
The Plan denied your request. The Plan says this is a packaged service which is not paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bupivacaine have not been met. Specifically, bupivacaine is a local anesthetic which would be considered integral to, and therefore included in the payment for the injection service provided. Therefore, we 
decided that the Plan does not have to pay for bupivacaine (J3490) provided on June 14, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory panel testing provided on August 1, 2023. 
 
You asked the Plan to pay for lab panel. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this testing should have been billed with 1 unit of a panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular syndromic panels for infectious 
disease pathogen identification testing must be billed with certain claim information, including a single unit of 
service of either a proprietary panel code or code 87999.  
 
We looked at the file and Medicare rules. This panel testing was not billed with a single unit of service of the 
appropriate procedure code. Based on this information, we decided that Medicare rules for coverage of lab 
panel have not been met. Therefore, we decided that the Plan does not have to pay for laboratory panel testing 
provided on August 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for code 99153 provided on January 17, 2023.

You asked the Plan to pay for code 99153. The Plan denied your request. The Plan says the Medicare billing
criteria were not met.

The Plan is correct in this case. The Plan follows Medicare rules. Medicare rules say that the OPPS recognizes
that CPT code 99153 is a "PE" only code and is not payable to the physician for services provided in the
facility setting. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare
rules for coverage of the services described by procedure code(s) 99153 have not been met. There is no
separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we
decided that the Plan does not have to pay for the services described by procedure code(s) 99153.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services provided from May 12, 
2023, to June 23, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON mental health services. You say that you stopped being a network 
provider with the Plan but continued to be paid for these services as an OON provider, until a claim was 
denied. You then were able to eventually obtain authorization to continue OON care but have not been able to 
get payment for the services provided before authorization was granted. You feel that this should be covered 
based on continuity of care. The Plan denied your request. The Plan says the services were not emergent and 
were provided without prior authorization for OON care.  
 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 the outpatient mental health services provided 
from May 12, 2023, to June 23, 2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lecanemab (Leqembi) (J0174). 
 
You asked the Plan to pre-approve lecanemab (Leqembi). You say that you are appealing based on medical 
necessity for treatment of mild cognitive impairment (MCI) due to Alzheimer's disease. The Plan denied your 
request. The Plan says the provider requested Leqembi (lecanemab) to treat Alzheimer's dementia. The Plan 
says that they determined Leqembi is not reasonable and necessary for this member.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  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 lecanemab (Leqembi). Our reviewer 
says that the elements of the coverage criteria for the requested drug has not been met. Our physician reviewer 
found the record provided does not indicate that the enrollee is enrolled, or intended to be enrolled, in the 
required approved studies or registry. Our physician reviewer also found that the record does not indicate that 
the provider is registered to participate in the required approved studies or registry. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lecanemab (Leqembi) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lecanemab (Leqembi) (J0174).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
(K0856) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair. You say that this is medically necessary for 
the enrollee. The Plan denied your request. The Plan says durable medical equipment is not covered for use in a 
skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a Group 3 power wheelchair is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option 
(K0856) and accessories.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
(Intracept procedure). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the enrollee has tried and failed 
conservative treatments without relief. 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 Intracept procedure is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not include magnetic resonance imaging (MRI) 
showing only Modic changes with facet degenerative joint disease or stenosis. The reviewer also found that there is no clear cause of the enrollee's pain. Therefore, the reviewer found that the requested Intracept 
procedure is not medically reasonable or 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 the Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve thermal destruction of intraosseous basivertebral nerve (Intracept procedure).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Opdualag (J9298) provided on October 18, 2022. 
 
You asked the Plan to pay for the drug. The Plan denied your request. The Plan says Opdualag is not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that Opdualag is 
not medically necessary. Our physician reviewer found that the records do not contain documentation of the 
though process or indication for the drug. Further documentation is needed to establish medical necessity. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pay for Opdualag (J9298) provided on October 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder orthosis provided on March 2, 2023. 
 
You asked the Plan to pay for the shoulder orthosis. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the item rendered was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must specify whether equipment is rented 
or purchased by using an appropriate modifier. 
 We looked at the file and Medicare rules. Review of the file shows that the claim was not billed with an 
appropriate modifier to clarify whether the equipment provided was rented or purchased. Without this required 
modifier, the claim is not payable as billed. Based on this information, we decided that Medicare rules for 
coverage of the shoulder orthosis have not been met. Therefore, we decided that the Plan does not have to pay 
for the shoulder orthosis provided on March 2, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bupivacaine (J3490) provided on May 15, 2023. 
 
You asked the Plan to pay for bupivacaine. You say that this drug was a medically necessary part of the 
enrollee's treatment. The Plan denied your request. The Plan says this drug was provided within the global 
period of minor surgery codes 64493 and 94494 and is not supported for separate payment. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for intra-operative services that are 
normally a usual and necessary part of a surgical procedure are included in the global surgical package 
payment. 
 
We looked at the file and Medicare rules. Bupivacaine is a local anesthetic which is normally a usual and 
necessary part of a surgical procedure. Therefore, it is included in the global surgery package and is not 
separately paid. Based on this information, we decided that Medicare rules for coverage of bupivacaine have 
not been met. Therefore, we decided that the Plan does not have to pay for bupivacaine (J3490) provided on 
May 15, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient or observation care provided on 
December 13, 2022. 
 
 
You asked the Plan to pay for initial hospital inpatient or observation care. You say that procedure code 99222 
is appropriate based on the services performed. The Plan denied your request. The Plan says the records do not 
support the services at issue in this case. 
 
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 99222 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's 
hospital floor or unit. 
 
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 initial hospital inpatient or observation care. Our reviewer 
says that the services at issue in this case were not supported by the medical records. Our reviewer found the 
documentation supports an appropriate history and examination; however, it does not support a moderate level 
of decision making or duration of encounter lasting 50 or more minutes as required to meet requirements for 
code, 99222.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial hospital inpatient or observation care have not been met. Therefore, we 
decided that the Plan does not have to pay for initial hospital inpatient or observation care provided on 
December 13, 2022.