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

We decided that the Plan does not have to pre-approvea peripheral nerve stimulator.You asked the Plan to pre-approvea peripheral nerve stimulator. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that a peripheral nerve stimulator is only covered for certain indications.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 a peripheral nerve stimulator. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has osteoarthritis of the right knee. The enrollee has had diagnostic Saphenous nerve block and genicular nerve blocks. The enrollee had Physical Therapy in the past. Intra-articular injections are mentioned but not clearly documented in the notes submitted. No orthopedic surgery consult is documented. The request is considered an experimental/investigational procedure and therefore, the request is deemed 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 a peripheral nerve stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approvea peripheral nerve stimulator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan 550mg tablets.
You asked the Plan to pre-approve the Xifaxan tablets. You say that this drug has been shown to be preferred
over other treatments. The Plan denied your request. The Plan says this oral drug is not covered by Medicare
Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan 550mg tablets.
Benefits for the Xifaxan tablets may be available under Medicare Part D. Contact the Plan that administers Part
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional routine transportation trips.You asked the Planto pre-approvethe additional trips. You say that this is medically necessary.The Plandenied your request. The Plansaysthe transportation benefit is exhausted.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 10 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plandoes not haveto pre-approveadditional routine transportation trips
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gauze, non-impregnated, sterile (A6219) and Hydrogel dressing, wound filler, gel, per fluid ounce (A6248) provided December 26, 2019.You asked the Plan to pay forthe wound supplies. You say that you are filling this appeal specifically requesting approval of the required DME supplies/wound care suppliesThe Plan denied your request. The Plan says payment for these items/services would have been included in the Part A payment.The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. The enrollee was an inpatient in a skilled nursing facility (SNF), therefore all services provided to the enrollee will be paid under the global facility claim. Payment for these service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for coverage of the wound supplies have not been met.Therefore, we decided that the Plan does not have to pay forthe gauze, non-impregnated, sterile (A6219) and Hydrogel dressing, wound filler, gel, per fluid ounce (A6248) provided December 26, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custodial care services.
You asked the Plan to pre-approve custodial care services. You say that you need assistance with routine
household chores. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. The rules say custodial care is not covered.
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of custodial care services have not been met. Therefore, we decided that the Plan does not have to
pre-approve custodial care services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approvean oximeterYou asked the Plan to pre-approvethe oximeter. You say that the requested pulse oximeter is recommended for monitoring the enrollee's oxygenation.The Plan denied your request. The Plan says that the requested device is not medically necessary, as the enrollee is not dependent on oxygen equipment for home use.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide any medical records or evidence of having made reasonable attempts to obtain medical records. The Plan's response to our request for this information was that the medical records were received with the appeal request, and there was therefore no attempt made to obtain medical records. However, the case file provided and the returned request for information did not include any valid medical records from the prescribing physician. Without this information, we are unable to determine whether the device is considered medically necessary and whether the enrollee has a condition that allows for coverage of the device. The Plan has not substantiated their denial.Therefore, we decided that the Plan has to pre-approvean oximeterIf the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forOphthalmology services (99214, 92136) provided July 27, 2020.You asked the Plan to waive the copayment forthe Ophthalmology services. You say that the copayment should be waived due to the ongoing COVID-19 pandemic.The Plan denied your request. The Plan says copayments are only being waived for in-network primary care, behavioral health, and telehealth services through the end of 2020. The Ophthalmology services are considered a specialist visit and the correct copayment was assessed.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 a $45 copayment for specialist visits. You have been asked to pay a $45 copayment for the Ophthalmology services. The Ophthalmology services fall within the specialist visits 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 towaive the copayment forOphthalmology services (99214, 92136) provided July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652).You asked the Plan to pre-approvea pneumatic compression device. You say that the enrollee has failed all other forms of conservative treatment including 4 week use of a basic pump.The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the documentation does not support that a qualifying 4 week trial of a basic compression pump has been performed.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegenetic testing.You asked the Plan to pre-approvegenetic testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested services.The Plan must follow Medicare rules. Medicare rules say that LS tumor screening with IHC or MSI is considered medically necessary and covered by Medicare for the following indications:-All individuals with colorectal cancer regardless of age OR-Individuals with endometrial cancerWe looked at the file and Medicare rules. Review of the file shows that the enrollee does not have a history of colorectal cancer or endometrial cancer. Based on this information, we decided that Medicare rules for coverageof genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approvegenetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient office visit (99203) provided July 22, 2020.You asked the Plan to waive the copayment forthe office visit. You say that this was scheduled as a cancer screening. You had a melanoma removed and a lot of lesions. You did not expect to pay a $40 copay for specialist for your cancer screening.The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied perthe Evidence of Coverage.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 $40 copayment for specialist office visits. You have been asked to pay $40 copayment specialist office visits for the office visit. the office visit falls within the Physician/Practitioner services, including doctor's office visits 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 copayment foroutpatient office visit (99203) provided July 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (82310, 80053) provided June 15, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the codes billed share a column I / column II relationship and are not
separately payable without a required modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 82310
has a Column I / Column II relationship with code 80053 and cannot be paid as billed. This code cannot be
paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (82310, 80053) provided June 15,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora second chest x-ray (CPT 71045) provided to the enrollee.

You asked the Plan to pay x-ray. You say that this should be paid for.The Plan denied your request. The Plan says a review of the records do not support the service as being performed twice on the same date of service.

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 71045 is "radiological examination, chest, single view.

"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 x-ray. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found a review of the dictation for the left thoracentesis on 4/10/20 indicates a post thoracentesis chest x-ray was obtained. Here the problem is that CMS considers a post procedure chest xray to be a part of the thoracentesis and a documentation of post procedure complications. There is only a single dictation for a single view chest x-ray on 410/20 which means that according to CMS a second charge, separate from the thoracentesis procedure is not a valid charge.

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 x-ray have not been met.Therefore, we decided that the Plan does not have to pay fora second chest x-ray (CPT 71045) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveretreatment of previous root canal therapy.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis service is not covered at this time.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 benefitin excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approveretreatment of previous root canal therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar artificial disc replacement services.
You asked the Plan to pre-approve the lumbar artificial disc replacement services. You say that the enrollee is
an ideal candidate for an L5-S1 disk arthroplasty. You say that the enrollee gets mostly axial back pain,
secondarily para spinal lumbosacral junction back pain. You say that when the enrollee's back pain is really
inflamed, she experiences numbness, tingling, dysesthesias and paresthesia in the L5-S1 area. You say that the
enrollee has not had any improvement over the past year, despite all non-operative treatment options having
been tried. You say that the medical records provided support the need for the requested service. The Plan
denied your request. The Plan says the requested service is not medically necessary under Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. In order to be covered and reimbursed, an item or service must meet several
requirements. It must fall within a defined benefit category, it cannot be excluded from coverage, either by
statute or policy, and it must be medically reasonable and necessary. In the absence of a National Coverage
Determination (NCD), discretion may be used to establish medical policy, currently known as Local Coverage
Determinations (LCDs). The purpose of this LCD is to create a working list of services and procedures that
have been evaluated by the Medical Policy staff, and determined that the services listed below do not meet the
reasonable and necessary criteria as defined in Section 1862 (a)(1)(A) of the Social Security Act. LCDs are
based on the strongest evidence available.
We looked at the file and Medicare rules. The contractor responsible for Medicare coverage in
the State, has determined that this service does not meet the criteria to be considered medically
reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve lumbar artificial
disc replacement services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecast post and core in addition to crown (D2952).You asked the Plan to pre-approvecast post and core in addition to crown (D2952). You say that the service is medically necessary.The Plan denied your request. The Plan says the service 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. The services covered under this benefit are listed in the Plan's 2020 EOC.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. Specifically, the service you received is not listed in the benefit chart. This means the service is not a covered benefit under this Plan.Therefore, we decided that the Plan does not have to pre-approvecast post and core in addition to crown (D2952).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve quantitative calcium scoring for the enrollee.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested type of testing is not supported without signs and/or symptoms of heart
disease.
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 imaging. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found in this setting screening cardiac CT scanning with calcium scoring is not recommended and has not been
shown to improve cardiac outcome incremental to that achievable based on treatment guided by standard
clinical risk profiling and basic lipid analysis alone.
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 imaging have not been met. Therefore, we decided that the Plan does not
have to pre-approve quantitative calcium scoring for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone scan to be provided by the out-of-network
provider.
You asked the Plan to pre-approve the bone scan. The Plan denied your request. The Plan says the services can
be provided in-network. The Plan restricts services to be provided in-network except for urgently or emergent
services.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a bone
scan to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea post and core in addition to a crown (D2954) for tooth # 8.You asked the Plan to pre-approvethe post and core in addition to a crown. You say that half of your tooth is exposed. You say that you had a root canal done but there is not enough tooth left to hold the filling. You say that you need a crown to cover the tooth. You also say that you need this to be approved before your tooth breaks off and causes more problems.The Plan denied your request. The Plan says post and core in addition to a crown is not listed as a covered service. The Plan also says that if a dental item or service is not listed in the benefit chart then it is 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. The Customer Handbookspecifically states that if a dental item or service is not listed in the benefit chart then it is not covered.Therefore, we decided that the Plan does not have to pre-approvea post and core in addition to a crown (D2954) for tooth # 8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does nothave to pre-approvea complete maxillary denture (D5110).You asked the Plan to pre-approvethe complete maxillary denture. You say that the enrollee needs her remaining teeth removed, and will need dentures made.The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit package.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 applyin 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-approvea complete maxillary denture (D5110).