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

 
We decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on 
June 11, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this is considered a bundled procedure. 
 
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 95999 is "unlisted neurological or neuromuscular 
diagnostic procedure." 
 
We asked our coding 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 testing. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found Train of 
Four Testing does not have a Current Procedural Terminology (CPT) code. This service is included with the 
primary service and not reported separately. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for train of four testing (CPT 95999) provided to the enrollee on June 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee 
did not have suicidal or homicidal ideation noted, and there were no auditory or visual hallucinations. It did not 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or 
others but was compliant with her treatment. The health plan?s denial of continued inpatient psychiatric 
services is appropriate. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to an inpatient mental health facility for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 13, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
laboratory services. 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 laboratory services provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 24, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
physicians services. 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 physician's services provided on July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee is not medically cleared to 
proceed with surgery. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood 
glucose testing at least four times per day. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implant for the enrollee. 
 
You asked the Plan to pre-approve the implant. You say that this is needed to help with fecal incontinence. The Plan 
denied your request. The Plan says there has been no trial of the stimulation device. 
 
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 implant. Our reviewer says that the requested services are 
not considered medically reasonable and necessary in this case. Our physician reviewer found there must be, prior to 
approval, a successful percutaneous test stimulation, defined as at least 50% sustained (more than one week) 
improvement in symptoms. The cumulative medical records through May 2020 fail to document such a test. Therefore, 
the enrollee does not meet coverage rules. 
 
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 implant have not been met. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous implant for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the lumbar spine for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary for lower extremity 
weakness and pain. The Plan denied your request. The Plan says there is no mention of physical therapy or 
muscle relaxants. 
 
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 not medically reasonable or necessary. Our physician reviewer found there is no 
documentation of a recent trial and failure of PT for back pain. There are no red flags. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the lumbar spine for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Pants-Up Easy device. 
 
You asked the Plan to pre-approve the device. You say that this will help you. The Plan denied your request. 
The Plan says this is not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the Pants-Up Easy device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hospital or ambulatory surgical center (D9420)and 
prefabricated stainless steel crown, permanent tooth, teeth 2, 4, 13, 14, 15, 29 (D2931). 
 
You asked the Plan to pre-approve the dental services. You say that the doctor only has privileges at the 
hospital and the procedure must be done in a hospital setting. The Plan denied your request. The Plan says 
these services are not covered under the plan benefits. 
 
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. The health plan contract says 
that any services not listed are not covered by the plan. 
 
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 
hospital or ambulatory surgical center (D9420)and prefabricated stainless steel crown, permanent tooth, teeth 2, 
4, 13, 14, 15, 29 (D2931).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gelsyn-3 knee injections (J7328). 
 
You asked the Plan to pre-approve Gelsyn-3 knee injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when the patient is 
symptomatic. Such symptoms may include pain which interferes with the activities of daily living such as ambulation and 
prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness. 
 
We looked at the file and Medicare rules. The records do not indicate the patient is symptomatic in regards to the knee 
and instead primarily document symptoms in other joints. Based on this information, we decided that Medicare rules for 
coverage of Gelsyn-3 knee injections have not been met. Therefore, we decided that the Plan does not have to pre-
approve Gelsyn-3 knee injections (J7328).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the computerized ophthalmic diagnostic 
imaging (92134) and the ophthalmological services (92014) provided on January 28, 2020 and July 28, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 for diagnostic 
procedures and tests enrollees must pay a $0 copayment for services provided by your primary care physician 
in their office. Additionally, you pay a $75 copayment for services performed by a provider other than your 
primary care physician.  
 
You have been asked to pay a copayment of $114.43 ($39.43 + $75) for the diagnostic tests provided. On 
January 28, 2020, a copayment of $39.43 was applied for computerized ophthalmic imaging. This was the Plan 
allowed amount for this service, which was less than the applicable copayment. Additionally, you had a yearly 
allowed vision exam on this day with no copayment responsibility. On July 28, 2020 you had a vision exam 
that would have applied a $25 copayment; however, you also received diagnostic services performed by a 
provider other than your primary care physician which applies a $75 copayment. You are responsible for the 
highest copayment amount when you receive more than one covered service where copays have been applied. 
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 adjust the copayment for the computerized ophthalmic 
diagnostic imaging (92134) and the ophthalmological services (92014) provided on January 28, 2020 and  
July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper and lower partial dentures. 
 
You asked the Plan to pre-approve the dentures. The Plan denied your request. The Plan says dentures are 
covered once every 60 months. 
 
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 are subject to a 
benefit limitation. The Plan covers partial dentures once every 60 months. The records show that you were 
provided covered partial dentures on January 24, 2020. This means that the requested dentures will exceed the 
benefit limit. Therefore, we decided that the Plan does not have to pre-approve upper and lower partial 
dentures.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (CPT 15734) provided to the enrollee on 
February 28, 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 procedure code 15734-51 is not supported by the medical records submitted. 
 
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 15734 is "Muscle, myocutaneous, or fasciocutaneous 
flap; trunk." 
 
We asked our coding 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 coding reviewer found the 
operative report did not include documentation that the muscle was mobilized, elevated, isolated on either its 
primary or secondary blood supply, then transferred locally or regionally to support procedure was performed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (CPT 15734) provided to the enrollee on February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D2740, D2950, D3320). 
 
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 the requested filling, crown, and nerve treatment are not covered under 
your dental 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 
dental services (D2740, D2950, D3320).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sensor (A9276) for use with a continuous glucose 
monitor. 
 
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered precautionary and not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that HCPCS A9276 is not a covered code. 
 
The requested item is meant for a non-therapeutic glucose monitor. Therefore, it is not covered. Based on this 
information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a sensor (A9276) for use with a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone anchored hearing aids provided to the enrollee on 
August 10, 2020. 
 
You asked the Plan to pay for these hearing aids. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare coverage criteria were not met. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of hearing device.  
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 these hearing aids. Our reviewer says that 
Medicare coverage criteria are not met. Our physician reviewer found the documentation does not support that 
the enrollee has bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from 
appropriate hearing (or vibrotactile) aids. Consequently, payment for bone anchored hearing implant for 
cochlear stimulation is not eligible for Medicare 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 these hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for bone anchored hearing aids 
provided to the enrollee on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal (endodontic therapy) and periodontal 
scaling and root planing. 
 
You asked the Plan to pre-approve these services. You say that not receiving the services will affect your 
medical conditions. The Plan denied your request. The Plan says the services are not covered. 
 
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 
root canal (endodontic therapy) and periodontal scaling and root planing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special service (99199), IV tubing extension (S1015) and 
infection control supplies (S8301) provided on August 19, 2020. 
 
You asked the Plan to pay for the special service, IV tubing extension and infection control supplies. You say 
that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan 
says CPT codes S1015 and S8301 have a status indicator of I which is not valid for Medicare purposes. 
 
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 codes 99199, S1015 and S8301 are not supported in the record. Specifically, per the 
Physician Fee Schedule, CPT codes S1015 and S8301 have a status indicator of I. This means that CPT code 
S1015 and S8301 are not valid for Medicare purposes. Additionally, 99199 represents an unlisted special 
service. The documentation submitted does not clearly indicate what services the PACU nurse provided and as 
such, it cannot be determined whether those services are separately payable.  Based on this information, we 
decided that Medicare rules for coverage of the special service, IV tubing extension and infection control 
supplies have not been met. Therefore, we decided that the Plan does not have to pay for the special service 
(99199), IV tubing extension (S1015) and infection control supplies (S8301) provided on August 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network dentist. 
 
You asked the Plan to pre-approve the referral. You say that the plan should reconsider coverage so that work 
can be done on your teeth. The Plan denied your request. The Plan says you have access to contracted providers 
in the area. 
 
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 referral to an out-of-network dentist.