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

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you need compression socks because of the size difference in your legs. The Plan denied your request. The Plan says the items are non-covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve office visit. You say that you have not had any relief with your current therapy. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.
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 an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physician services provided on April 22, 2021 by
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (93005, G0402, G0463) provided to the 
enrollee on January 29, 2021. 
 
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 there were multiple medical visits on the same day with the same revenue code with out 
condition code G0. 
 
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 the denied codes is: 
 
CPT 93005: 
 
Electrocardiogram, routine ECG with at least 12 leads 
 
HCPCS G0402: 

Initial Preventive Physical Examination; face-to-face visit, services limited to a new patient during the first 12 
months of Medicare enrollment 
 
HCPCS G0463: 
 
Hospital outpatient clinic visit for assessment and management of a patient 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found 
Healthcare Common Procedure Coding System (HCPCS) G0402 and G0463 was submitted to the health plan 
without an added modifier G0, which is required when multiple visits are made on the same day, same 
facility/provider with the same revenue code. Therefore, these services are not eligible for reimbursement. 
 
We looked at this physician's review, the file, and Medicare rules. The services at issue in this case (G0463, 
G0402, 93005) were not reported correctly. 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 
physician services (93005, G0402, G0463) provided to the enrollee on January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for provisional splinting - extracoronal (D4321 x3) provided on April 1, 2021.
You asked the Plan to pay for provisional splinting - extracoronal. You say that you thought that these services would be covered. The Plan denied your request. The Plan says the services at issue are not a covered benefit.
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 pay for provisional splinting - extracoronal (D4321 x3) provided on April 1, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you do not require skilled services on a daily basis which can only be provided on an inpatient basis in the SNF level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 3 power wheelchair and accessories.
You asked the Plan to pre-approve the group 3 power wheelchair and accessories. You say that this request is
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for a
group 3 power wheelchair have not been met.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for
enrollees who have a mobility limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition,
myopathy or congenital skeletal deformity. Since the criteria for a base wheelchair have not been met, the
subsequent accessories will also be denied. Therefore, we decided that the Plan does not have to pre-approve
the group 3 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical supplies provided from October 5, 2020, to February 5, 2021.
You asked the Plan to waive the coinsurance for medical supplies. You say that there is no way for you to pay these bills. The Plan denied your request. The Plan says the coinsurance amounts you are being charged are correct. The Plan also says that they have approved payment for the supplies provided on February 5, 2021 with 20% coinsurance applied to the claim.
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% coinsurance for medical supplies. The allowed amounts of these claims total $813.56, resulting in a total
coinsurance amount of $162.72. You have been asked to pay 20% coinsurance for medical supplies. Medical supplies fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 medical supplies provided from October 5, 2020, to February 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Western Blot proprietary testing for Lyme disease.
You asked the Plan to pre-approve Western Blot proprietary testing for Lyme disease. You say that you feel this test should be covered. The Plan denied your request. The Plan says you do not meet criteria for the requested services.
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 Western Blot proprietary testing for Lyme disease. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have chronic persistent Lyme disease and is receiving treatment. The provided record indicates that the requested test is not being used to guide subsequent therapy. You have been diagnosed and are receiving treatment. The requested test is not medically necessary and reasonable, as defined by Medicare rules, in your specific clinical condition. The elements of the coverage criteria are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Western Blot proprietary testing for Lyme disease have not been met. Therefore, we decided that the Plan does not have to pre-approve Western Blot proprietary testing for Lyme disease.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation (D4921 x4) provided on March 24, 2021.
You asked the Plan to pay for gingival irrigation. You say that you were not aware that this service was not covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 pay for gingival irrigation (D4921 x4) provided on March 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you need the SNF treatment to build up your strength again and get therapy to assist with the healing process. The Plan denied your request. The Plan says the stay is 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 in the Medicare rules section 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You are receiving wound care thrice weekly and can receive antibiotics at dialysis. You do not have documented skilled therapy needs. You remain non-weight bearing to both lower extremities and appear to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not 
covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies rendered from October 21, 2020 to
November 11, 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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS
suppliers are required to maintain proof of delivery.
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 infusion supplies rendered from October 21, 2020 to
November 11, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infrared therapy services provided on March 22, 2021.
You asked the Plan to pay for the services provided. You say that the code does not reflect the treatment you received. The Plan denied your request. The Plan says naturopathic services are excluded from coverage.
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 97026 is application of a modality to 1 or more areas; infrared. We find that CPT code 97026 is not supported in the medical record. The records provided do not show that this service was provided. 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 pay for the infrared therapy services provided on March 22, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 6, 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 procedure codes 27690, 28299, 28730, and 27692 are not covered. 
 
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 27690 is transfer or transplant of single tendon (with 
muscle redirection or rerouting); superficial (eg, anterior tibial extensors into midfoot). The definition of code 
28299 is correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with double 
osteotomy, any method. The definition of code 28730 is arthrodesis, midtarsal or tarsometatarsal, multiple or
transverse. The definition of code 27692 is transfer or transplant of single tendon (with muscle redirection or 
rerouting); each additional tendon (List separately in addition to code for primary procedure). 
 
We find that CPT codes 27690, 28299, 28730, and 27692 are not supported in the medical record. Specifically, 
there is no documentation of superficial transfer or transplant of a single tendon to support code 27690. There 
is no documentation of correction of hallux valgus to support code 28299. There is no documentation of 
multiple or transverse midtarsal or tarsometatarsal arthrodesis to support code 28730. There is no 
documentation of transfer or transplant of a single tendon for each additional tendon to support code 27692. 
 
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 February 6, 
2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits. 
 
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically 
necessary. The Plan denied your request. The Plan says additional PT is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 ten (10) additional PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the additional requested therapy was not 
generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by 
the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of 
a professional therapist are required to safely and effectively provide treatment, that the services can be safely 
and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a 
therapist. The enrollee's functional level did not require ongoing formal skilled PT. The requested services 
were not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified 
therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to 
prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that Ambulatory Blood Pressure Monitoring (ABPM) is reasonable and necessary for the diagnosis of hypertension in Medicare beneficiaries with suspected white coat hypertension or suspected masked hypertension as defined in the NCD. We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee meets the specifications for suspected white coat hypertension or suspected masked hypertension. Specifically, the records do not show that two separate measurements were made at each visit. Based on this information, we
decided that Medicare rules for coverage of an automatic blood pressure monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CGM and supplies (CPT code(s): A9278, A9276, A4364, A9277).
You asked the Plan to pre-approve the CMG and supplies. You say that there is no quality of life in pricking yourself every day without knowledge of how bad your diabetes is or how fast your condition is deteriorating. You state approval of the device can improve heath. The Plan denied your request. The Plan says the Medicare rules 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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. You are not insulin dependent and do not check glucose levels more than four (4) time daily per the medical records provided. Based on this information, we decided that Medicare rules for coverage of the CMG and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve CGM and supplies (CPT code(s): A9278, A9276, A4364, A9277).