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

 
We decided that the Plan does not have to pay for procedure code(s) 88312, 88112, and 88305 billed for date of 
service December 21, 2022. 
 You asked the Plan to pay for procedure code(s) 88312, 88112, and 88305. You say that these services were 
billed correctly. The Plan denied your request. The Plan says these codes are included in the facility payment 
and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88312, 88112, and 
88305. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88312, 
88112, and 88305. Based on this information, we decided that Medicare rules for coverage of procedure code 
88312, 88112, and 88305 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88312, 88112, and 88305 billed for date of service December 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MPL (MPL proto-oncogene, thrombopoietin receptor) 
(eg, myeloproliferative disorder) gene analysis; sequence analysis, exon 10 (81339), CALR (calreticulin) (eg, 
myeloproliferative disorders), gene analysis, common variants in exon 9 (81219), and JAK2 (Janus kinase 2) 
(eg, myeloproliferative disorder) targeted sequence analysis (eg, exons 12 and 13) (81279). 
 
You asked the Plan to pre-approve MPL, CALR, and JAK2. 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 genetic testing is 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 MPL, CALR, and JAK2. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the records do not indicate 
that the enrollee has completed the step-by-step (sequential) testing as required by the Medicare rules. The 
review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MPL, CALR, and JAK2 have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative 
disorder) gene analysis; sequence analysis, exon 10 (81339), CALR (calreticulin) (eg, myeloproliferative 
disorders), gene analysis, common variants in exon 9 (81219), and JAK2 (Janus kinase 2) (eg, 
myeloproliferative disorder) targeted sequence analysis (eg, exons 12 and 13) (81279).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 25, 2023. 
 
You asked the Plan to pay for an office visit. You say that you did not know that you had to officially ask for a 
referral. 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 visit provided 
on August 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation (RFA). 
 
You asked the Plan to pre-approve sacroiliac joint RFA. You say that sacroiliac joint RFA is medically 
necessary. The Plan denied your request. The Plan says a review of the current medical literature does not 
support this procedure to be reasonable and necessary. This procedure is considered an 
experimental/investigational procedure because of the wide variation in efficacy reported in the 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 pre-approve sacroiliac joint RFA. Our reviewer says 
that the requested sacroiliac joint RFA is not considered medically reasonable and necessary. Our physician 
reviewer found sacroiliac joint RFA is considered experimental therapy because of the wide variation in 
efficacy reported in the peer reviewed literature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint RFA.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lumbosacral spine x-rays provided on April 
12, 2023. 
 
You asked the Plan to waive the copayment for lumbosacral spine x-rays. You say that you have never had to 
pay for x-rays before. 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 $35 
copayment for standard routine x-rays. 
 
You have been asked to pay a $35 copayment for lumbosacral spine x-rays. This item/service falls within the 
standard routine x-rays benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for lumbosacral 
spine x-rays provided on April 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Interspinous Spacer. 
 
You asked the Plan to pre-approve a Vertiflex Interspinous Spacer. You say that you are in increasing pain in 
your thigh muscles and numbness in your left foot making it too hard to walk and this surgery would help with 
this. The Plan denied your request. The Plan says this service is not considered to be the accepted standard of 
medical practice. 
 
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 Vertiflex Interspinous Spacer. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Vertiflex device is experimental.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex Interspinous Spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Vertiflex Interspinous Spacer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 16, 2022, billed 
with codes 87640, 87653, 87481, 87798, and 87186. 
 

You asked the Plan to pay for the genetic testing billed. You say that the services were provided per the 
enrollee's medical condition. 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. 
 
The file shows that a urinary tract infection panel was provided. We looked at the file and Medicare rules. This 
NGS panel that was not billed with a single 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 December 16, 2022, billed with codes 87640, 87653, 
87481, 87798, and 87186.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet the criteria for the IRF admission.  
 
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. 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. 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 as medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve apically positioned flap (D4245), the localized delivery 
of antimicrobial agents (D4381) for teeth numbers 3,5, and 4, gingivectomy or gingivoplasty to allow access 
for restorative procedure (D4212) for tooth number 3, occlusal adjustment (D9951), an unspecified adjunctive 
procedure (D9999) times two, and a porcelain crown fused to high noble metal (D2750) for tooth number 3. 
 
You asked the Plan to pre-approve apically positioned flap (D4245), the localized delivery of antimicrobial 
agents (D4381) for teeth numbers 3,5, and 4, gingivectomy or gingivoplasty to allow access for restorative 
procedure (D4212) for tooth number 3, occlusal adjustment (D9951), an unspecified adjunctive procedure 
(D9999) times two, and a porcelain crown fused to high noble metal (D2750) for tooth number 3. You say that 
this is a health issue and is not getting resolved. You also say you need a crown at a reasonable cost. The Plan 
denied your request. The Plan says apically positioned flap (D4245), the localized delivery of antimicrobial 
agents (D4381) for teeth numbers 3,5, and 4, gingivectomy or gingivoplasty to allow access for restorative 
procedure (D4212) for tooth number 3, occlusal adjustment (D9951), and an unspecified adjunctive procedure 
(D9999) times two are excluded from this benefit. The Plan also says the Plan only covers base metal crowns 
for molars, and the request is for a higher grade of metal for the crown. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
apically positioned flap (D4245), the localized delivery of antimicrobial agents (D4381) for teeth numbers 3,5, 
and 4, gingivectomy or gingivoplasty to allow access for restorative procedure (D4212) for tooth number 3, 
occlusal adjustment (D9951), an unspecified adjunctive procedure (D9999) times two, and a porcelain crown 
fused to high noble metal (D2750) for tooth number 3.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the enrollee has tried and failed 
conservative treatment without relief. The science supporting the safety and effectiveness of the procedure is 
robust. The Plan denied your request. The Plan says the request does not meet the standard of care because 
imaging, examination and symptoms reveal additional significant pathology that is unlikely to benefit from the 
procedure and is not approved. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging showing only modic changes without facet 
degenerative joint disease or stenosis. The cause of pain is not clear. Medical necessity is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (L1843) and suspension sleeve 
(L2397). 
 
You asked the Plan to pre-approve the orthoses. You say that you are submitting appeal request along with 
clinical which shows that CPT L1843 is medically necessary for the enrollee. The Plan denied your request. 
The Plan says under Medicare guidelines, this request 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 orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the presented with left knee pain. The evaluation suggests osteoarthritis without findings of 
joint laxity or other knee instability. The LCD requires the presence of joint instability to qualify for the 
requested orthotic. There is no other rationale for medical necessity to authorize the orthotic. 
 
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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the knee orthosis (L1843) and suspension sleeve (L2397).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87150, 87481, 87500, 87641, 87653, 
87798 and 87801) billed for date of service May 30, 2023. 
 
You asked the Plan to pay for laboratory services. You say that this testing was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says two of the billed diagnosis codes cannot be 
reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that N39.0 has an Excludes1 note in relation to N30.90. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for laboratory services (87150, 87481, 87500, 87641, 87653, 87798 and 87801) billed for date of service 
May 30, 2023.
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 goal is to get you back to yourself as you were 
completely mobile prior to your admission to the hospital. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary.  
 
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 that you do not need physician supervision 3 times a week or intensive therapy 3 
hours a day and 5 days per week with a multidisciplinary approach in an IRF. While you may benefit from 
physical and occupational therapy your needs can be provided in an alternate setting such as skilled nursing 
facility.  
 
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 pay for the pneumatic compression device provided on June 12, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you were in an accident and lost 
your denture. The Plan denied your request. The Plan says your benefit for the requested service has already 
been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested service was exhausted on date of service February 22, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care provided on February 09, 2023. 
 
You asked the Plan to pay for initial hospital care. You say that this is supported in the records. 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 initial hospital care 
provided on February 09, 2023.