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

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on July 16, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation received does not include definitive laboratory results for 22 or more drug classes to support the coding criteria.
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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." We 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found 22 or more drug classes were not tested. The records do not support the coding of HCPCS G0483. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on July 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the wheelchair and accessories. You say that you would like reconsideration
because at the time of the request, you were the only company with a stock custom wheelchair. The Plan
denied your request. The Plan says the member can receive this equipment in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that Durable Medical Equipment is not covered out-of-network.
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
the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvegradient compression stockings (A6534).You asked the Planto pre-approvethe compression stockings. You say that this is medically necessary.The Plandenied your request. The Plansaysthe records available for review do not indicate presence of skin breakdown, or venous insufficiency ulcer or other wound.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plandoes not haveto pre-approvegradient compression stockings (A6534)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 4, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for the drug testing (80307 and G0482). You say that you would like reconsideration
because this testing was time sensitive and medically necessary. The Plan denied your request. The Plan says
these services were rendered by an out-of-network provider and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
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 medical services provided on August 4, 2020
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4260 x 2) and an occlusal adjustment
(D9951).

You asked the Plan to pre-approve the dental services. You say that the enrollee's primary care provider (PCP)
referred the enrollee for these services stating that they were medically necessary. The Plan denied your
request. The Plan says osseous surgery is not listed as a covered service. The Plan also says that occlusal
adjustment is not listed as a covered service.

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, 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
osseous surgery (D4260 x 2) and an occlusal adjustment (D9951).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on July 20, 2020,
through September 1, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because
this is not durable medical equipment and was not delivered to the member's home. The Plan denied your
request. The Plan says this code is not recognized by the Plan for non-contract providers.
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 code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes.
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328)
provided on July 20, 2020, through September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heel lift for the enrollee.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically needed.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve a heel lift for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laser destruction of a congenital hemangioma of the
neck coded as 17106, 17107 and 17108.

You asked the Plan to pre-approve the laser treatment. You say that treatment for these lesions is deemed
medically necessary. You do not treat these lesions for cosmetic reasons. The Plan denied your request. The
Plan says the requested service is not covered under Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the laser treatment have not been met. Therefore, we decided that the Plan does not have to preapprove
laser destruction of a congenital hemangioma of the neck coded as 17106, 17107 and 17108.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided on September 22, 2020
to September 25, 2020 by an out of network (OON) provider.

You asked the Plan to pay for inpatient hospital care. You say that the services were medically necessary. The
Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.

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 inpatient hospital care provided on September
22, 2020 to September 25, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 10 and core build
up (D2950) for tooth # 9.

You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The
Plan denied your request. The Plan says porcelain crown is not listed as a covered service. The Plan also says
that core build up is not listed as a covered service.

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, 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 a
porcelain crown (D2740) for tooth # 10 and core build up (D2950) for tooth # 9.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection (ESI).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that an ESI 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has neck and low back
pain. The office visit on December 28, 2020 documents a cervical spine computed tomography (CT) scan
demonstrating degenerative disc changes. There is no documentation of objective radiculopathy on
examination. The CT scan did not demonstrate nerve root impingement. The ESI is therefore not reasonable or
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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an epidural steroid injection (ESI).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve
branches including imaging guidance, when performed (64624).

You asked the Plan to pre-approve Destruction by neurolytic agent, genicular nerve branches including
imaging guidance, when performed. You say that the service is medically necessary. The Plan denied your
request. The Plan says the service 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 Destruction by neurolytic agent,
genicular nerve branches including imaging guidance, when performed. Our reviewer says that the requested
service is not considered medically reasonable and necessary in this case. Our physician reviewer found this is
considered an experimental/ investigational procedure that is the subject of on-going clinical trials. Therefore,
the request is considered 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 Destruction by neurolytic agent, genicular nerve branches including imaging
guidance, when performed have not been met. Specifically, this service is considered experimental and cannot
be medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve
destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
(64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialty absorptive dressing, conforming bandage,
and gauze.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that surgical dressings 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral leg ulcers. The
ulcers have not been debrided in some time due to pain and inability to provide adequate analgesia in the
outpatient setting. The main issue is significant drainage that requires the use of ABO pads and gauze wraps to
maintain an appropriate amount of moisture to the wounds but not an excessive amount. The enrollee is being
seen in a wound care clinic but the wounds are not being debrided and she has not had surgery. The requested
surgical dressings are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a specialty absorptive dressing, conforming bandage, and gauze.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 31, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
authorization was not obtained by the provider or the facility. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 6, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until September 21, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the services provided on July 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Inqovi tabs. 
 
You asked the Plan to pre-approve Inqovi tabs. The Plan denied your request. The Plan says this medication 
does not fall under Part B. 
 
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 Inqovi tabs.  
 
Benefits for Inqovi tabs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acupuncture consult. 
 
You asked the Plan to pre-approve the acupuncture consult. You say that you would like reconsideration 
because these services are medically necessary. The Plan denied your request. The Plan says the documentation 
submitted does not support the medical necessity of the requested service 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record does not show that you have chronic low 
back pain. Therefore, we decided that the Plan does not have to pre-approve the acupuncture consult.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate for the 
enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requirements were not met. 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found although the requested device is FDA-approved, the enrollee does not have all of the required 
indications, including persistent symptoms despite maximal medical management and conventional medical 
therapy. There is an additional contraindication of the enrollee being over 80 years old. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transurethral waterjet ablation of prostate for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the left transforaminal epidural steroid injection at
L3&4 (Codes: 64483/64484) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve steroid injections. You say that the services are medically necessary. The
Plan denied your request. The Plan says there are in-network providers that can provide this service.
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. The Plan has provided you with a list of five network providers
within thirty miles of your home that can provide this service. Therefore, we decided that the Plan does not
have to pre-approve the left transforaminal epidural steroid injection at L3&4 (Codes: 64483/64484) to be
provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four pulp vitality tests. 
 
You asked the Plan to pre-approve pulp vitality tests. You say that your provider advised that there was not 
disease on the tooth, but you need a root canal and a crown. The Plan denied your request. The Plan says this 
service is not covered under your benefit plan. 
 
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, 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 four 
pulp vitality tests.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvewheelchair van transportation.You asked the Plan to pre-approvewheelchair van transportation. The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pre-approve are wheelchair van transport services.Therefore, we decided that the Plan does not have to pre-approvewheelchair van transportation