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

We decided that the Plan has to pay for the anesthesia services provided on November 1, 2019.
You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says that the use
of general anesthesia for routine pain procedures is warranted only in unusual circumstances.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 anesthesia services. Our physician
reviewer found that the enrollee underwent bilateral medial branch block (MBB) bilateral L3-4, L4-5, L5-S1
facet joints. The procedure was performed under monitored anesthesia care (MAC). The anesthesiology record
documented that this enrollee was an ASA 3. This is defined as severe systemic disease that limits activity, but
is not incapacitating, e.g., stable angina, history of myocardial infarction, history of stroke, insulin dependent
diabetes, poorly controlled disorders, hypertension, asthma, psychiatric disorders, dysrhythmias, CHF, and
COPD. The records document that an anesthesiologist was present for MAC and a pain management physician
for the procedures performed. The records showed that the anesthesia services were provided by a separate
provider and were medically necessary and reasonable.
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 anesthesia services have been met. Therefore, we decided that the Plan has
to pay for the anesthesia services provided on November 1, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 1, 2019
to December 20, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the enrollee was approved while under
Medicare and Medicaid. You also say that the enrollee was switched to a different plan as of December 1,
2019, and because the services were approved prior to, you would like this to be paid. The Plan denied your
request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from December 1, 2019 to December 20,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services (97810, 97026, 99203, 97811)
provided on January 20, 2020 to January 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON acupuncture services. You say that the referral you received should be
back dated to cover these services. The Plan denied your request. The Plan says these dates of service were not
authorized.
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 the acupuncture services (97810, 97026, 99203,
97811) provided on January 20, 2020 to January 23, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 8 additional extractions (D7140) the filling (D2330) for
tooth # 22, and the pin retention (D2951) provided from October 22, 2019 to November 13, 2019.
You asked the Plan to pay for 8 additional extractions, 1 additional filling, and the pin retention. You say that
you thought the provider in this case was a network provider. The Plan denied your request. The Plan says 2
extractions per calendar year are covered. The Plan says that 2 fillings per calendar year are covered. The Plan
says the frequency limits for these services have been exceeded. The Plan also says that pin retention is not 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 and extractions and fillings are covered
services, the frequency limits for these services have been exceeded. The record shows that the Plan previously
paid for the extraction of tooth # 3 that you received on October 22, 2019 and a filling for tooth # 10 that you
received on November 13, 2019. Additionally, pin retention is not a service that is covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the 8 additional extractions (D7140) the filling
(D2330) for tooth # 22, and the pin retention (D2951) provided from October 22, 2019 to November 13, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the right knee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary to determine an
aggressive treatment until you can have surgery. The Plan denied your request. The Plan says that this MRI
would not add additional information that is required to treat your condition.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 pre-approve the MRI. Our reviewer says that the
requested MRI is medically reasonable and necessary. Our physician reviewer found you have clinical
symptoms, and radiological findings of degenerative joint disease of the left and right knees. You have had the
required six week course of supervised PT. The MRI is very reasonable in order to assess not only the extent of
the degenerative joint disease, but also to evaluate the various tendons and ligaments of the knee, as well as the
potential for loose bodies within the knee.
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve
MRI of the right knee.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic appliance (E0657) provided on January 23, 2020.
You asked the Plan to pay for the pneumatic appliance. You say that you would like reconsideration because this supply is medically necessary. The Plan denied your request. The Plan says CPT code E0657 was not billed with the required durable medical equipment modifier
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 E0657 is not supported in the record. Specifically, E0657 is a capped rental item meaning id cannot be provided for purchase using modifier -NU. This supply must be billed with the -RR modifier. Based on this information, we decided that Medicare rules for coverage of the pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic appliance (E0657) provided on January 23, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for nerve conduction studies (95910) and needle electromyography
(95886) provided on September 23, 2019.
You asked the Plan to pay for nerve conduction studies and needle electromyography. You say that these
studies are documented. The Plan denied your request. The Plan says that these codes are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of
code 95910 is nerve conduction studies; 7-8 studies and 95886 is needle electromyography, each extremity,
with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity
study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels
(List separately in addition to code for primary.
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 nerve conduction studies and needle
electromyography. Our reviewer says that these codes are supported by the records. Our physician reviewer
found the report indicates that nerve conduction studies of the bilateral peroneal, posterior tibial, sural, and H
reflexes were performed, supporting 95910. The report also indicates that studies of five or more muscles in the
lower extremities across four or more spinal levels were performed and chronic abnormalities were reported,
supporting 95886.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of nerve conduction studies and needle electromyography have been met.
Therefore, we decided that the Plan has to pay for nerve conduction studies (95910) and needle
electromyography (95886) provided on September 23, 2019.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 97162 provided on July 18, 2019.
You asked the Plan to pay for CPT code 97162. You say that the medical records support the billing of CPT
code 97162. The Plan denied your request. The Plan says the medical records do not support the billing of CPT
code 97162.
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 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 CPT code 97162. Our reviewer says that the
medical records do not support the billing of CPT code 97162. Our physician reviewer found CPT 97162 was
performed by a Physical Therapy Assistant (PTA) on July 18, 2019. Per the code description, there is Clinical
decision making of moderate complexity, which does not fall within the scope of a Physical Therapy Assistant.
Per the American Physical Therapy Association, "In summary, PTs must examine, evaluate, screen, diagnose,
determine a prognosis, develop plans of care, oversee documentation and care, and discharge patients. PTAs
are highly trained in providing treatment interventions for patients and are an asset for patient care, especially
when the PT and PTA have a mutually trusting and respectful relationship."
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CPT code 97162 have not been met. Therefore, we decided that the Plan does
not have to pay for CPT code 97162 provided on July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652).
You asked the Plan to pre-approve the pneumatic compressor. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says the member has not had a four
week trial of a non-segmental compression pump.
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 pneumatic compressor. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the documentation does not reveal objective physical exam findings of
lymphedema in the chest,trunk abdomen. There is no evidence that the member had a sufficient trial of a
nonsegmented device in conjunction with a segmented appliance or a segmented compression device without
manual control of pressure in each chamber.
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 pneumatic compressor have not been met. Therefore, we decided that the
Plan does not have to pre-approve a pneumatic compressor (E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for definitive drug testing provided on April 24, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the
documentation did not include a physician order or medical records stating exactly what tests are to be
performed.
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 G0482 is definitive drug testing of 15-21 drug classes.
We find that CPT code G0482 is not supported in the medical record. In this case, there were insufficient
records that show the tests were needed to identify specific substances that were inadequately detected by a
presumptive drug test. There is no evidence that shows the test was individualized to identify 15-21specific
non-prescribed medications or illicit substances. Based on this information, we decided that Medicare rules for
coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for
definitive drug testing provided on April 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for low osmolar contrast material (Q9966) provided on December 13, 2019.
You asked the Plan to pay for the low osmolar contrast material. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the units 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. 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 low osmolar contrast material. Our reviewer says that the documentation does not support that 10 units of Omnipaque 240mg/ml was given. Our reviewer found the record indicates that 2 cc were given. 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 low osmolar contrast material have not been met. Therefore, we decided that the Plan does not have to pay for low osmolar contrast material (Q9966) provided on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Lite test strips.
You asked the Plan to pre-approve the FreeStyle Lite test strips. You say that the FreeStyle test strips are
medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that plans may choose a preferred brand for durable
medical equipment.
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 FreeStyle Lite test strips. Our
reviewer says that the requested FreeStyle test strips are not medically necessary. Our physician reviewer found
the record shows no reason why the enrollee cannot use the plan preferred OneTouch brand.
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 FreeStyle Lite test strips have not been met. Therefore, we decided that the
Plan does not have to pre-approve FreeStyle Lite test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis (20610) and dexamethasone sodium phosphate
(J1100) provided on November 19, 2019.
You asked the Plan to pay for the arthrocentesis and dexamethasone sodium phosphate. 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 services 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 20610 is arthrocentesis, aspiration and/or injection; major
joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa).
The CPT Code Manual of code J1100 is injection, dexamethasone sodium phosphate, 1mg.
We find that CPT code 20610 and J1100 is not supported in the record. Specifically, the record does not
indicate that these services were rendered. There is insufficient information to verify the services at issue.
Based on this information, we decided that Medicare rules for coverage of the arthrocentesis and
dexamethasone sodium phosphate have not been met. Therefore, we decided that the Plan does not have to pay
for arthrocentesis (20610) and dexamethasone sodium phosphate (J1100) provided on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis provided on November 20, 2019 by an outof-
network (OON) provider.
You asked the Plan to pay for the knee orthosis provided out-of-network. You say that the records provided
support the services billed. The Plan denied your request. The Plan says external prosthetic devices and
appliances are not covered out of network. The Plan says that is would require authorization for an out-ofnetwork
provider to be obtained prior to services being rendered unless it is an urgent or emergent situation.
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 a knee orthosis provided on November 20, 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 functional electrical stimulator (E0770, E1399).
You asked the Plan to pre-approve functional electrical stimulator. You say that you are asking for approval of
these devices so you can safely continue an active lifestyle for as long as you can. The Plan denied your
request. The Plan says medical necessity for a functional electrical stimulation system has not been met
because the records do not show you have a spinal cord injury.
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 functional electrical stimulator. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found in this case the enrollee does not have a history of a spinal cord injury (as
required by the NCD for coverage of a FES device). Nor does the enrollee meet the requirements for coverage
of a NMES device as defined by the NCD. The enrollee's issues related to disuse atrophy are primarily due to
her neurological conditions (MS and a history of spine problems which necessitated multiple surgical
interventions). The enrollee would therefore also not meet the NCD requirements for coverage of a NMES
device. Taking all of these factors into consideration the requested device would not meet Medicare criteria for
coverage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of functional electrical stimulator have not been met. Therefore, we decided that
the Plan does not have to pre-approve functional electrical stimulator (E0770, E1399).