Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the
enrollee on December 30, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the orthosis have not been met. Documentation submitted did not
indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be
verified. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis
(L3960) provided to the enrollee on December 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for cataract surgery provided on February 11,
2020.
You asked the Plan to waive the coinsurance for cataract surgery. You say that your wife had the same surgery
and had no coinsurance. You say that you shouldn't have to pay this. The Plan denied your request. The Plan
says the coinsurance applied 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 20% of
the cost for each outpatient hospital and ambulatory surgery visit.
You have been asked to pay $230.34, which is 20% of the allowed amount for cataract surgery. The allowed
amount is $1,151.72 (20% x $1,151.72 = $230.34). Cataract surgery falls within the "Outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 coinsurance for cataract surgery provided on February 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study rendered on November 19, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 93971 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 93971 and 93970. Code 93971 is a column II code with a
modifier indicator of 1 when billed with column I code 93970. Code 93971 was not billed with an appropriate
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the
extremity study rendered on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64495) provided on November 7, 2019.
You asked the Plan to pay for the facet joint injections. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the service billed.
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 64495 is injection(s), diagnostic or therapeutic agent,
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or
CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary
procedure).
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 the facet joint injections. Our reviewer says that CPT code
64495 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical
records do not include information to support injection(s), diagnostic or therapeutic agent, paravertebral facet
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or
sacral; third and any additional level(s) (List separately in addition to code for primary procedure) being
performed on November 7, 2019, as only two facet joints are documented as being blocked, therefore, this code
cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pay for facet joint injections (64495) provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and physician services provided on January 9,
2020 by an out of network (OON) provider.
You asked the Plan to pay for an office visit and physician services. You say that you would like this claim
reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was
obtained. The Plan says that the member's primary care physician did not approve these services.
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 has network providers
available who can provide 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 an office visit and physician services provided on
January 9, 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 extractions on teeth #7-13, 23-27, and 29 (D7140),
surgical removal of erupted teeth for teeth #22 and 30 (D7210), alveoloplasty in conjunction with extractions
- four or more teeth or tooth spaces, per quadrant (D7310 x2), deep sedation/general anesthesia - first 15
minutes (D9222), and deep sedation/general anesthesia - each 15 minute increment (D9223 x3).
You asked the Plan to pre-approve extractions on teeth #7-13, 23-27, and 29, surgical removal of erupted teeth
for teeth #22 and 30, alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces,
per quadrant, deep sedation/general anesthesia - first 15 minutes, and deep sedation/general anesthesia - each
15 minute increment. You say that the services are necessary The Plan denied your request. The Plan says the
requested services exceed the covered benefits. Therefore, coverage criteria has not been met.
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. The Plan covers two nonsurgical
or surgical extractions per calendar year and necessary anesthesia with covered services.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of extractions on teeth #7-13, 23-27, and 29, surgical removal of erupted teeth for teeth #22 and 30,
alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant, deep
sedation/general anesthesia - first 15 minutes, and deep sedation/general anesthesia - each 15 minute
increment have not been met. Therefore, we decided that the Plan does not have to pre-approve extractions on
teeth #7-13, 23-27, and 29 (D7140), surgical removal of erupted teeth for teeth #22 and 30 (D7210),
alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310
x2), deep sedation/general anesthesia - first 15 minutes (D9222), and deep sedation/general anesthesia - each
15 minute increment (D9223 x3).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Mvasi (Q5107).
You asked the Plan to pre-approve the Mvasi. You say that you would like reconsideration as this drug is
medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says
that Mvasi must be used in combination with carboplatin and paclitaxel when used for this member's
indication.
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 pre-approve the Mvasi. Our reviewer says that the
use of Mvasi for this condition is supported by the major drug compendia and clinical research. Our physician
reviewer found the Mvasi is safe and effective and otherwise reasonable and necessary for this member.
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 Mvasi have been met. Therefore, we decided that the Plan has to preapprove
Mvasi (Q5107).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services provided on October 24, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for the services provided. You say that the tests were performed in good faith. The
Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and
authorization for certain services.
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 documentation shows that portable x-ray services were provided. The requested provider in this case is not
a network provider with the Plan. The Plan has network providers available who can provide the services at
issue in this appeal. 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 the
imaging services provided on October 24, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed or a powered pressure
reducing mattress.
You asked the Plan to pre-approve a total electric hospital bed with rails and powered pressure reducing
mattress. You say that the enrollee's current hospital bed is being picked up soon. The Plan denied your request.
The Plan says a power mattress and a total electric bed are not covered but they will approve a semi-electric
bed with rails.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. The record shows the enrollee does not have pressure ulcers so a powered pressure
reducing mattress is also not covered by Medicare or the Plan. Therefore, we decided that the Plan does not
have to pre-approve a total electric hospital bed or a powered pressure reducing mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an attendant control.
You asked the Plan to pre-approve an attendant control. You say that the enrollee needs the power wheelchair.
The Plan denied your request. The Plan says an attendant control cannot be covered in addition to a
beneficiary-operated joystick.
The Plan must follow Medicare rules. Medicare rules say that if an attendant control is provided in addition to a
beneficiary-operated drive control system, it will be denied as non-covered.
We looked at the file and Medicare rules. An attendant control cannot be covered in addition to the enrolleeoperated
device control system already approved by the plan. Based on this information, we decided that
Medicare rules for coverage of an attendant control have not been met. Therefore, we decided that the Plan
does not have to pre-approve an attendant control.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for treatment of a leg fracture provided on July 18, 2019.
You asked the Plan to pay for the fracture treatment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim has been billed with a device dependent code without a required device code for the same date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 29855 is not supported in the record. Specifically, CPT code 29855 is a device dependent procedure. This claim has not been billed with an appropriate code for the required device. Based on this information, we decided that Medicare rules for coverage of the fracture treatment have not been met. Therefore, we decided that the Plan does not have to pay for treatment of a leg fracture provided on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic colonoscopy (45378) and anesthesia for lower intestinal endoscopic procedures (00811, 00812) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a diagnostic colonoscopy and anesthesia for lower intestinal endoscopic procedures to be provided by an OON provider. You say that you prefer to have the procedure performed by this provider since you have an established history with him. The Plan denied your request. The Plan says there are in-network providers that are able to provide this service. Therefore, coverage criteria has not been met.
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 a diagnostic colonoscopy (45378) and anesthesia for lower intestinal endoscopic procedures (00811, 00812) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the
enrollee on January 24, 2020.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the orthosis have not been met. Documentation submitted did not
indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be
verified. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis
(L3960) provided to the enrollee on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, knee orthosis and suspension
sleeve provided on October 18, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the knee orthosis (L1851) and suspension
sleeve (L2397). You say that the orthoses are medically necessary. The Plan denied your request. The Plan says
the orthoses are not medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the knee orthosis (L1851) and suspension
sleeve (L2397). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found
Coverage of a lumbar-sacral orthosis and bilateral knee orthoses with suspension sleeves has been requested.
At issue is whether the requested orthoses were medically reasonable and necessary in this case, according to
the coverage criteria established by the LCDs. The enrollee's chief complaints were chronic pain in the lower
back pain and right knee, as well as in the right shoulder and right wrist. The available documentation in the
case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for
the enrollee in this case, according to the coverage criteria established by the LCD. A physical examination of
the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been
met. The documentation does not support that the lumbar-sacral orthosis is being prescribed for one or more of
the covered indications in this case, as there is no documentation of a credible physical examination of the
back.
The documentation in the case file does not support that the requested knee orthoses with sleeves were
medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established
by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the
enrollee's knees, and there is insufficient credible objective documentation of joint laxity.
The item coded L2397 (sleeve) is not separately payable when the base item is not covered.
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 knee orthosis (L1851) and suspension sleeve (L2397) have not been met.
Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis, knee orthosis and
suspension sleeve provided on October 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee
on January 14, 2020.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the orthoses have not been met. HCPCS Code L1971 -LT -KX and
L1971 -RT -KX - DOS January 14, 2020. Documentation submitted did not indicate the provider discussed the
need for the billed supply code; therefore, the billed supply code cannot be verified.
Therefore, we decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to
the enrollee on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on January 22, 2020.
You asked the Plan to waive the copayment for laboratory tests. You say that you previously had the same test and no copayment applied. You say that a copayment doesn't apply to lab tests as part of an office visit. The Plan denied your request. The Plan says the copayment applied 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 $10 for Medicare-covered laboratory tests. You have been asked to pay a $10 copayment for the laboratory tests. The laboratory tests fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 laboratory tests provided on January 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (TOF - testing to monitor the depth of
muscle relaxation during surgery - coded as 95999 - Unlisted neurological or neuromuscular diagnostic
procedure provided to the enrollee on October 17, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the services have not been met. The record sent by your provider
indicates that you underwent back surgery requiring neurophysiology monitoring. Other neuromonitoring
services have been approved for payment by the Plan. Under Medicare guidelines, your request is not a covered
benefit because Medicare does not make separate payment for this service. We are unable to approve this
request. The enrollee will not be responsible for this payment as the cost is included in the cost of the primary
procedure. Therefore, we decided that the Plan does not have to pay for train of four testing (TOF - testing to
monitor the depth of muscle relaxation during surgery - coded as 95999 - Unlisted neurological or
neuromuscular diagnostic procedure provided to the enrollee on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sure Inj 140mg/Ml.
You asked the Plan to pre-approve Repatha Sure Inj 140mg/Ml. You say that the requested medication is
necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not
include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been
met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Repatha Sure Inj
140mg/Ml.
Benefits for Repatha Sure Inj 140mg/Ml may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.