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

We decided that the Plan does not have to pay forthe unlisted neurological or neuromuscular diagnostic procedure services coded 95999 provided on June 13, 2019.You asked the Plan to pay forthe unlisted neurological or neuromuscular diagnostic procedure 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 separately 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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, these services are considered a bundled procedure and are included in the cost of the primary procedure. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure services have not been met.Therefore, we decided that the Plan does not have to pay forthe unlisted neurological or neuromuscular diagnostic procedure services coded 95999 provided on June 13, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral carotid duplex scan.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a carotid duplex scan is covered when specific
criteria are met.
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 services are not medically necessary. Our physician reviewer found the submitted records show that you
have blockage of the precerebral arteries. Your doctor requested a bilateral carotid duplex scan to evaluate for
carotid artery stenosis. The records do not support that you meet the criteria for coverage of the requested scan.
The carotid duplex is therefore not reasonable or medically necessary at this time.
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 a bilateral carotid duplex scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator provided on January 9, 2020.
You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that you disagree with the increase in charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
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 durable medical equipment and related supplies. You received an oxygen concentrator on January 9, 2020. The allowed amount is $122.12 and 20% of that is $24.42. You have been asked to pay the total coinsurance amount of $24.42 for an oxygen concentrator. An oxygen concentrator falls within the Durable medical equipment and related 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 an oxygen concentrator provided on January 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem.You asked the Plan to pre-approveZolpidem. You say that the enrollee has responded well to, and tolerated well, this medication.The Plan denied your request. The Plan says this oral self-administered medication is not covered underMedicare Part A or 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 drugrequested here isnot among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveZolpidem.Benefits for Zolpidemmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95907) and needle electromyography (95887 and 95885) provided on July 15, 2019.
You asked the Plan to pay for the nerve conduction studies and needle electromyography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records submitted do not support the services 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 CPT Code Manual definition of code 95907 is nerve conduction studies; 1-2 studies. The CPT Code Manual definition of code 95887 is needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure).
We asked our coder 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 nerve conduction studies and needle electromyography. Our reviewer says that CPT codes 95907, 95887 and 95885 do not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted indicate that pedicle screws were triggered by electromyography. This description does not meet the definition/description of CPT code 95907, therefore, it is inappropriate to bill CPT code 95907 to represent the services provided on July 15, 2019. Additionally, 95887 and 95885 are add-on codes. The primary procedure (95907) has been denied, therefore CPT codes 95887 and 95885 are not eligible for payment. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies and needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95907) and needle electromyography (95887 and 95885) provided on July 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diagnostic mammogram provided on November 20, 2019.
You asked the Plan to waive the deductible for the diagnostic mammogram. You say that you should not have to pay the whole bill. You say you found the problem yourself, went to your physical and were sent over to radiology. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $300 deductible that applies towards diagnostic mammograms. The diagnostic mammogram you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible that applies towards diagnostic mammogram. The record shows a diagnosis of an unspecified breast lump which makes the mammogram diagnostic in nature.
This cost sharing is a contractual obligation that had not been met at the time the diagnostic mammogram was received on November 20, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic mammogram provided on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for IV infusions (96366x3) and therapeutic or diagnostic injections (96375x3) provided on July 12, 2019.
You asked the Plan to pay for the IV infusions and injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the number of units billed for these services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder 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 IV infusions and injections. Our reviewer says that CPT codes 96366x3 and 96375x3 do not meet criteria for billing or reimbursement consideration. Our reviewer found based on the start and stop times of the Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) in the medical record, 1:25 p.m. to 3:00 p.m. and 3:10 p.m. to 4L45 p.m., CPT code 96366 should be billed at 2 units. Additionally, the medical records submitted only supports 2 units of CPT 96375. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the IV infusions and injections have not been met. Therefore, we decided that the Plan does not have to pay for IV infusions (96366x3) and therapeutic or diagnostic injections (96375x3) provided on July 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on October 28, 2019.
You asked the Plan to waive the copayment for cataract surgery. You say that you were unable to proceed with the procedure. You say that the cataract extraction was not performed. The Plan denied your request. The Plan says the copayment applied correctly.
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 $300 copayment for Medicare-covered outpatient surgery at an in-network ambulatory surgery center. You have been asked to pay a $300 copayment for cataract surgery. Cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show the procedure was cancelled after anesthesia was administered. 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 for cataract surgery provided on October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the total body vibration machine purchased on June 7, 2019.
You asked the Plan to reimburse you for the total body vibration machine. You say that the total body vibration machine is medically necessary for your medical condition. The Plan denied your request. The Plan says the provider is not a Medicare certified provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the total body vibration machine purchased on June 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation.
You asked the Plan to pre-approve the consultation. 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 consultation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the documentation provided, the enrollee has been seen by multiple providers within her network and has been treated within the standard of care. Her visual symptoms and clinical exam can be attributed to dry eye syndrome, refractive error, and strabismus, which have been appropriately treated. She does not have a condition that warrants her to be seen for a second opinion outside of her network. 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 consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says documentation submitted did not support the diagnosis
used on the submitted order or that the provider discussed the need for the orthosis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The office visit notes do not support medical necessity for the
orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis
(L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral
orthosis
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (PWC).
You asked the Plan to pre-approve the PWC. You say that you have lots of pain and have a high risk of falling. You need this PWC to help you get around. The Plan denied your request. The Plan says there is not sufficient evidence that the requested PWC is needed for use in the home.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you are able to complete the MRADLs in the home with the help of a wheeled walker. The power wheelchair is requested for mobility outside of the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (PWC).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided by an outpatient hospital facility on November 4, 2019.
You asked the Plan to waive the copayment for arthrocentesis. You say that you disagree with the charges for an injection. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received arthrocentesis on November 4, 2019. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for arthrocentesis. Arthrocentesis falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 for arthrocentesis provided by an outpatient hospital facility on November 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care provided to the enrollee from February 14, 2020 through February 19, 2020.
You asked the Plan to pre-approve inpatient mental health care. You say that the member is currently receiving ECT treatment and her treatment team would like to continue with further ECT treatments, as the patient is showing some positive response. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our reviewer says that [state physician reviewer's conclusion, e.g. "the service is not medically necessary." or "you need this medical item."] Our physician reviewer found based on review the records provided, this patient has not shown improvement with the treatment of Electroconvulsive Therapy (ECT). This patient had been showing continued suicidal ideation with thoughts of hanging herself, not trusting staff and continued depression. Based on the information provided, this patient does not meet criteria for the use of Electroconvulsive Therapy (ECT) beyond February 14, 2020 utilizing LCD 33624. Additional treatments are not reasonable or medically necessary as this patient does not meet criteria for the use of ECT.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care provided to the enrollee from February 14, 2020 through February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D2752, D22391, D1206, D2392) provided September 4 to December 13, 2019 by an out-of-network provider.
You asked the Plan to pay for the out-of-network dental services. You say that the services should be covered. The Plan denied your request. The Plan says dental services rendered out-of-network are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental services (D2752, D22391, D1206, D2392) provided September 4 to December 13, 2019 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esomeprazole Magnesium DR 40 MG Capsules (J8499).You asked the Plan to pre-approve Esomeprazole Magnesium DR 40 MG Capsules. You say that the prior authorization has been denied and you are requesting an appeal.The Plan denied your request. The Plan says this drug is taken orally and therefore, is not a covered benefit.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 Esomeprazole Magnesium DR 40 MG Capsules (J8499).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a commode chair that can be placed over a toilet.
You asked the Plan to pre-approve the commode chair. You say that this would be helpful as raised toilet seats have not been beneficial. The Plan denied your request. The Plan says this is not covered in this circumstance.
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room and that raised toilet seats are noncovered as they are not medical in nature. It is noted that the enrollee has a bedside commode but that one for use over the toilet is requested. This indicates that the enrollee is not considered room-confined and also that the commode is being requested as a sturdier alternative to a raised toilet seat. A commode is only covered by Medicare when needed for use in a room in which the enrollee is confined, meaning, that he/she cannot access a toilet. Therefore, we decided that the Plan does not have to pre-approve a commode chair that can be placed over a toilet.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 19, 2019.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says there is no valid referral for this serviceMedicare 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 caseis not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 a domiciliary, rest homevisit provided on December 19, 2019.