Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of an endosteal implant (D6010)
for teeth # 22 and 37, and a prefabricated abutment (D6056) for teeth # 22 and 27.
You asked the Plan to pre-approve the prefabricated abutment. You say that not having teeth affects your
ability to eat. You also say that you are only able to eat certain foods that upset your stomach. The Plan denied
your request. The Plan says the prefabricated abutment is not listed as 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, 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
surgical placement of an endosteal implant (D6010) for teeth # 22 and 37, and a prefabricated abutment
(D6056) for teeth # 22 and 27.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office consultation for a new or established patient services coded 99243 provided on September 3, 2019.
You asked the Plan to pay for the office consultation for a new or established patient. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 99243 is Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99243 is not supported in the medical record. Specifically, code 99243 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of the office consultation for a new or established patient have not been met. Therefore, we decided that the Plan does not have to pay for the office consultation for a new or established patient services coded 99243 provided on September 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin barrier rendered on
June 7, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code A5120 was not billed with the required modifier.
The Plan must follow Medicare rules. The rules say that modifier AW must be billed with an item furnished in
conjunction with a surgical dressing.
We looked at the file and Medicare rules. The provider billed code A5120 (skin barrier) without the required
AW modifier. Therefore, we decided that the Plan does not have to pay for the skin barrier rendered on June 7, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (90867, 90868, and 90869).You asked the Plan to pre-approve transcranial magnetic stimulation. You say that the requested transcranial magnetic stimulation is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested transcranial magnetic stimulation.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 transcranial magnetic stimulation. Our reviewer says that the enrollee does not meet Medicare criteria for the requested transcranial magnetic stimulation. 
Our physician reviewer found the request is for coverage of Transcranial Magnetic Stimulation (TMS) treatment for Major Depressive Disorder, Recurrent Episode, Severe without Psychotic Features, Unspecified Anxiety Disorder, ruled out Posttraumatic Stress Disorder, History of Obsessive-Compulsive Disorder and History of Opiate Dependence. Based on review of the records provided and utilizing the Medicare local coverage determination (LCD) for transcranial magnetic stimulation, Medicare guidelines have not been met. Based on the information provided this enrollee does not meet the criteria for Transcranial Magnetic Stimulation (TMS) based on the LCD (L33398) as there is no documentation of the enrollee undergoing or having undergone evidence-based psychotherapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transcranial magnetic stimulation have not been met.Therefore, we decided that the Plan does not have to pre-approvetranscranial magnetic stimulation (90867, 90868, and 90869)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood glucose monitor (E2100), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a lancing device (A4258) provided on July 30, 2019 to October 18, 2019.

You asked the Plan to pay for a blood glucose monitor, test strips, lancets, calibrator solution, and a lancing device. You say that these items should be covered. The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the delivery ticket and the proof of delivery did not corroborate one another in regards to an order number and carrier. Therefore, we decided that the Plan does not have to pay for a blood glucose monitor (E2100), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a lancing device (A4258) provided on July 30, 2019 to October 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular junction testing coded 95937 provided on
July 22, 2019.
You asked the Plan to pay for the neuromuscular junction testing. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.
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 95937 is neuromuscular junction testing (repetitive
stimulation, paired stimuli), each nerve, any 1 method.
We find that CPT code 95937 is not supported in the medical record. Specifically, the documentation does not
support that this code was performed. The documentation indicates that train of four testing/monitoring was
performed. This services performed does not meet guidelines for code 95937. Based on this information, we
decided that Medicare rules for coverage of the neuromuscular junction testing have not been met. Therefore,
we decided that the Plan does not have to pay for the neuromuscular junction testing coded 95937 provided on
July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by the out of network
provider.
You asked the Plan to pre-approve specialist services. You say that the enrollee would like to see an out-of-network doctor. The Plan denied your request. The Plan says this doctor is out-of-network. The Plan says that
there are in-network providers who can provide the services that are needed.
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 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 has approved a consult with an in-group neurologist. 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 the medical services to be
provided by the out of network provider.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing visits in the home (CPT G0299).
You asked the Plan to pre-approve the home skilled nursing visits. You say that the enrollee requires 3-5 visits
per week from a skilled RN for wound care. The Plan denied your request. The Plan says that the requested
services have been found to be not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home skilled nursing visits. Our
reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee received
oral medications and had stable vital signs. She was treated for chronic pressure ulcers with dressings to her left
posterior leg, left hip and right hip. She attended dialysis three times per week. She was seen by a wound care
nurse who monitored her wounds and performed debridement. The records document that she could not
perform the wound care herself. Skilled nursing visits are required to effectively provide treatment, care, and/or
services which are medically necessary for the enrollee.
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 home skilled nursing visits have been met. Therefore, we decided that the
Plan has to pre-approve skilled nursing visits in the home (CPT G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce to the copayment forthe inpatient hospital stay provided from September 11, 2019 to September 12, 2019.You asked the Plan to reduce to the copayment forthe inpatient hospital stay. You say that you are being charged $1,610 .00 for your hospital stay. You say you should only be charged $370 a day. The Plan denied your request. The Plan says a $370 copaymentThe 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 a $370 copayment per day, days 1-5 for each Medicare-covered hospital stay.You have been asked to pay a $370 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" 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 paywhen you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce to the copayment forthe inpatient hospital stay provided from September 11, 2019 to September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on September 4, 2019 by the out of network provider.
You asked the Plan to pay for an office visit. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service September 4, 2019. The Plan denied your request. The Plan says the doctor is a non-participating provider. The Plan says it did not authorize any services for the out of network provider. The Plan also says that there are multiple in-network providers within 30 miles of the members residence that could have rendered the services. The services are not considered urgent/emergent in nature.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on September 4, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve duplex scan of extracranial arteries for the enrollee.
You asked the Plan to pre-approve the scan. 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. 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 scan. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not meet health plan criteria for coverage and does not support the medical necessity of the study in question. Review of the enrollee's complaints does not include any neurologic complaints. Review of systems only describes difficulty with concentration. No carotid bruit is documented. There is no documentation of results of any previous potential carotid studies. The presence of dizziness and giddiness in her problem list is not satisfactory documentation of current or recent symptomatology. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve duplex scan of extracranial arteries for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on May
29, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure codes J3411 and 96372 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 J3411 is injection, thiamine hcl, 100 mg. The definition
of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or
intramuscular.
We find that CPT codes J3411 and three units of code 96372 are not supported in the medical record.
Specifically, the documentation does not show that an injection of thiamine HCl, 100 mg was administered to
support code J3411. The documentation shows that two injections were administered; therefore, three units of
code 96372 are not supported. 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 services rendered
 on May 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from August 29, 2019 to September 5, 2019.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from August 29, 2019 to September 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 2, 2019 by out of network provider
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 were rendered by a non-contracted provider without prior authorization.
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 medical services provided on August 2, 2019 by out of network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on September 26, 2019.
You asked the Plan to pay for the prophylaxis. You say that you were told to have your teeth cleaned four times a year due to your medical condition. The Plan denied your request. The Plan says your contract provides benefits for this procedure twice in a benefit period.
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, routine preventive teeth cleanings are limited to a maximum of 2 per calendar year. The record shows that you received one prophylaxis on January 17, 2019 and a second prophylaxis on May 31, 2019 and your routine preventive teeth cleanings benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 17, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says urgently
needed services may be accessed from contracted urgent care centers. If providers are temporarily unavailable
or inaccessible and it is not reasonable to wait to obtain care from your network provider when the network
becomes available, we will cover urgently needed services that you get from an out-of-network 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 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 physician's services provided on January 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFerumoxytol.You asked the Plan to pre-approveFerumoxytol. You say that this has been recommended by your provider to help with your low levels of red blood cells.The Plan denied your request. The Plan says that IV iron infusion isnot medically necessary at this time as the member is progressing on oral iron.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Ferumoxytol. Our reviewer says that that Ferumoxytol is not medically reasonable and necessary in this case. The submitted documentation shows that on the oral iron your hemoglobin, hematocrit, iron, iron binding capacity and ferritin have all improved. There is no documentation that the enrollee is not tolerating the oral iron. Our physician reviewer found that your condition does not meet Medicare criteria for Ferumoxytol.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ferumoxytol have not been met.Therefore, we decided that the Plan does not have to pre-approveFerumoxytol.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies coded as E2100, A4253, A4256, A4258 and A4259 provided on August 7, 2019 to October 26, 2019.
You asked the Plan to pay for the diabetic supplies. You say that that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket submitted. Therefore, we decided that the Plan does not have to pay for the diabetic supplies coded as E2100, A4253, A4256, A4258 and A4259 provided on August 7, 2019 to October 26, 2019.