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

We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.You asked the Plan to pre-approve these services. You say that these services are medically necessary.The Plan denied your request. The Plan says that this service is considered experimental and investigational.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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The enrollee is being treated for spinal stenosis, lumbar region, with neurogenic claudication. She presented with continued weakness in her legs. Exam reveals pain with lumbar extension and bilateral lateral flexion. There is pain with bilateral facet loading maneuver. Gait is antalgic with forward leaning posture. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. 
This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis (including the planned level of implantation at L3/4 and L4/5). FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and which have not been adequately addressed in the medical records. There is imaging evidence of grade 1 retrolisthesis of L2 on L3 which measures 2mm with no discussion of potential spinal instability on flexion/extension films. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.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 the Superion interspinous spacer for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic appliance (E0666) provided on September 11, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the pneumatic appliance. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 pneumatic appliance (E0666) provided on September 11, 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 four extractions (D7210) provided on December 16, 2020.
You asked the Plan to pay for the extractions. You say that these teeth were removed in relation to a tumor in your jaw and should be covered as a medical procedure. The Plan denied your request. The Plan says there is no coverage for dental services provided out-of-network.
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. If you receive services out-ofnetwork,
you are responsible for 100% of the cost.
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received out-ofnetwork
are not covered under this benefit. You state that these teeth were removed because of a tumor in your
jaw. No medical records were provided in support of this, and it is unclear whether these teeth were removed in
order to prep the jaw for tumor removal or if the tumor caused the teeth to break, which led to the necessity of
their removal. The Plan also only covers medical services received out-of-network in limited circumstances.
Therefore, we decided that the Plan does not have to pay for four extractions (D7210) provided on December
16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology consultation and report on referred slides prepared elsewhere (88321) provided November 11, 2020.
You asked the Plan to pay for surgical pathology consultation and report. You say that please review the enclosed documentation and reprocess your claim for payment as medically necessary. The Plan denied your request. The Plan says code 88321 was not billed in accordance with Medicare National Correct Coding Initiative Policy - medically unlikely edits.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 88321 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of surgical pathology consultation and report have not been met. Therefore, we decided that the Plan does not have to pay for surgical pathology consultation and report on referred slides prepared elsewhere (88321) provided November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 2, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0648) knee orthosis (L1833)
suspension sleeve (L2397) provided October 13, 2020.

You asked the Plan to pay for the orthoses. You say that you received an EOB with a denial for misrepresented
services. Attached please find medical records, packing list, POD and WOL. The Plan denied your request.

The Plan says this supplier is not enrolled/certified with Medicare and evidence of misrepresented services.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0648) knee
orthosis (L1833) suspension sleeve (L2397) provided October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on October 29, 2020.You asked the Plan to pay for eye refraction. You say that you were reimbursed $25 so think you should be paid more.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by the Plan.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a routine eye examination up to a $75 allowance but does not cover eye refraction.We looked at the file and the Plan's rules. Refraction is not covered by the Plan's supplemental vision benefits. Based on this information, we decided that the Plan's rules for coverage of eye refraction have not been met.Therefore, we decided that the Plan does not have to pay for an eye refraction provided on October 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 31, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 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 services provided by an out-of-network provider on March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 28, 2020.
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 the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 27093 is 1. You billed 2 units of this code, exceeding the MUE. 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 pay for the surgical services rendered on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora routine eye exam (S0621) and eye refraction (92015) provided on October 28, 2020.You asked the Plan to pay for the eye exam and refraction. You say that you did not know this provider was not part of this network and did not know that you should have used a network provider.The Plan denied your request. The Plan says they have paid the full $75 allowance for these services, but because you used an out-of-network provider, you are responsible for the remaining cost.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $75. If you use a provider that is part of the Plan's specified vision network, the cost for these services will not exceed $75. If you use an out-of-network provider, you will be responsible for costs above the Plan's allowance amount.We looked at the file and the Plan's rules. The provider in question is not part of the Plan's specified optical network, and the Plan has paid the full allowance of $75 for these services. You have been asked to pay the remaining cost up to the providers charges.There is no indication that you contacted the Plan prior to receiving services to find a provider or verify this provider's network status.Based on this information, we decided that the Plan's rules for full coverage of the eye exam and refraction have not been met.Therefore, we decided that the Plan does not have to pay the full cost for the routine eye exam (S0621) and eye refraction (92015) provided on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 3, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services 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 had network providers available who could have provided 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 services provided by an out-of-network provider on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
January 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services 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 had network providers available who could have provided 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 services provided by an out-of-network provider on January 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the electrophysiology services provided from February 19, 2021, to February 24, 2021.

You asked the Plan to waive the cost share for the services provided. You say that the services were incorrectly classified. The Plan denied your request. The Plan says the claim was processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for diagnostic procedures and tests in an outpatient hospital.

You have been asked to pay a 20% coinsurance for the services provided. The services fall within the outpatient hospital services 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 cost share for the electrophysiology services provided from February 19, 2021, to February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 19, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 office visit provided on January 19, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier (D4266), bone replacement graft for ridge preservation (D7953), surgical placement of implant body: endosteal implant (D6010), prefabricated abutment - includes modification and placement (D6056), and abutment supported porcelain/ceramic crown (D6058).

You asked the Plan to pre-approve guided tissue regeneration, bone graft, endosteal implant, prefabricated abutment and abutment supported crown. You say that you cannot afford the cost of the services. The Plan denied your request. The Plan says these services are not covered under your benefits.

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 guided tissue regeneration - resorbable barrier (D4266), bone replacement graft for ridge preservation (D7953), surgical placement of implant body: endosteal implant (D6010), prefabricated abutment - includes modification and placement (D6056), and abutment supported porcelain/ceramic crown (D6058).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI), any joint of lower
extremity.

You asked the Plan to pre-approve magnetic resonance imaging, any joint of lower extremity; without contrast
material (73721). You say that your right knee hurts so much you cannot sleep at night. The Plan denied your
request. The Plan says the records do not show you have had a recent six-week trial of doctor prescribed
treatment.

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 magnetic resonance imaging, any joint
of lower extremity; without contrast material (73721). Our reviewer says that the MRI is not medically
necessary. Our physician reviewer found detailed documentation is not evident regarding trial and failure of
recent, reasonable and comprehensive less invasive conservative care measures including. Furthermore, x-rays
are noted to appear diagnostic, and it is not clear how additional imaging would change the course of treatment
(as conservative measures are being recommended). There is no compelling rationale presented or extenuating
circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for
right knee MRI is 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 magnetic resonance imaging, any joint of lower extremity; without contrast
material (73721) have not been met. Therefore, we decided that the Plan does not have to pre-approve a
magnetic resonance imaging (MRI), any joint of lower extremity.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve auricular percutaneous electrical nerve stimulation.
You asked the Plan to pre-approve auricular percutaneous electrical nerve stimulation. You say that this item is medically necessary. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulation is not covered. We looked at the file and Medicare rules. In this case, this item is not covered by either Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of auricular percutaneous electrical nerve stimulation have not been met. Therefore, we decided that the Plan does not have to pre-approve auricular percutaneous electrical nerve stimulation.