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

We decided that the Plan does not have to pay for the two indirect pulp caps and two resin-based composites provided on January 21, 2020.
You asked the Plan to pay for the indirect pulp caps and resin-based composites. You say that you had two fillings provided. You also say that due to work, you elected to have services rendered on two more teeth. The Plan denied your request. The Plan says indirect pulp cap is not a covered benefit. The Plan also says that the benefits for resin-based composites have been satisfied and the frequency limitation has been exceeded.
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, indirect pulp cap is not among those covered under this benefit. The contract says that restorations are limited to two procedures per calendar year. The record shows that you received four resin-based composites on January 21, 2020, two of which were covered at the in-network rate by the Plan, and your restorations benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the two indirect pulp caps and two resin-based composites provided on January 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 2, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forpatient education materials (99071) provided on November 25, 2019.You asked the Plan to pay forpatient education materials. You say that this should be reprocessed.The Plandenied your request. The Plan says payment for this service is bundled into other 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 find that CPT code 99071 is not supported in the medical record. Specifically, this code has a status code of B. Payment for covered services are always bundled into payment for other services not specified.Based on this information, we decided that Medicare rules for coverage of patient education materials have not been met.Therefore, we decided that the Plan does not have to pay forpatient education materials (99071) provided on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames and lenses (V2750, V2781, V2200, V2020) provided October 26, 2019.
You asked the Plan to pay for the eyewear. You say that the items were medically necessary. The Plan denied your request. The Plan says you do not have any supplemental coverage for routine vision items or services. The eyewear is not covered under Medicare benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for eyeglass frames and lenses (V2750, V2781, V2200, V2020) provided October 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) provided on November 26, 2019. You asked the Plan to pay for the EEG. The Plan denied your request. The Plan says the EEG was 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 pay for the EEG. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that performance of an electroencephalogram (EEG) (CPT 95955) during this type of surgery is not within the standard of care. This is primarily due to the fact that an EEG provides no clinical value/utility to the surgeon, nor does it have any bearing on health outcomes. The use of a limited channel EEG during this type of procedure was not otherwise furnished in accordance to the standards of practice/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 the EEG have not been met.Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) provided on November 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vertebroplasty and/or sacroplasty.You asked the Plan to pre-approve the procedure. You say that this is needed for repair of spinal fractures.The Plan denied your request. The Plan says asacroplasty is a different procedure from a vertebroplasty, and is not covered under Medicare guidelines.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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records indicate that the fracture is older than 6 weeks and is associated with spinal canal stenosis. Therefore, vertebroplasty is not indicated. Sacroplasty is experimental 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 the procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve a vertebroplasty and/or sacroplasty.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCoflex interspinous and/or interlaminar device (22867, 22868).You asked the Plan to pre-approveCoflex interspinous and/or interlaminar device. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 Coflex interspinous and/or interlaminar device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has not met the FDA indications for Coflex. Therefore, this request for the Coflex interspinous and/or interlaminar device is not medically reasonable and 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 Coflex interspinous and/or interlaminar device have not been met.Therefore, we decided that the Plan does not have to pre-approveCoflex interspinous and/or interlaminar device (22867, 22868).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided on December 18, 2019.
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says in-area urgent care
must be received in-network. The enrollee is not home bound and the care was not urgent enough to be needed
out-of-network while in-area.
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 a home visit provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99292) provided to the enrollee on September 28, 2019.
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 Current Procedural Terminology (CPT) code 99292 remains 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 99292 is "Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes." We asked our coding 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 coded correctly. Our coding reviewer found the medical records provided do not include documentation the the critical services provided exceeded the 30 - 74 minutes of critical care services to validate the need to bill CPT 99292, therefore this service cannot be verified. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (CPT 99292) provided to the enrollee on September 28, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90834) provided on December 26, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were non-emergent. There were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services (90834) provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 5mg methadone (S0109) provided on January 1, 2018 through December 18, 2019.
You asked the Plan to pay for the methadone. You say that you would like reconsideration because you have had to pay out of pocket. The Plan denied your request. The Plan says methadone is a non-covered benefit under Medicare and the Plan.
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. Additionally, the documentation submitted does not include any medical records to confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for 5mg methadone (S0109) provided on January 1, 2018 through December 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 37214 provided on February 14, 2020.You asked the Plan to pay for CPT code 37214. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, CPT code 37214 has a MAI of "2". Based on this information, we decided that Medicare rules for coverage of CPT code 37214 have not been met.Therefore, we decided that the Plan does not have to pay for CPT code 37214 provided on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing exam (V5008) and hearing aids (V5259 , V5160 and V5266) provided on February 1, 2019.
You asked the Plan to pay for the hearing services. You say that you would like reconsideration because the Plan should be responsible for part of the payment for out-of-network services. The Plan denied your request. The Plan says services were not received from a network provider and you did not received network hearing aids.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing services and aids only when they are received from a network provider. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing services have not been met. Specifically, the record indicates that these services were not received from a network provider. Therefore, we decided that the Plan does not have to pay for a hearing exam (V5008) and hearing aids (V5259 , V5160 and V5266) provided on February 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMacrobid capsules.You asked the Plan to pre-approveself-administered drugs. You say that you are requesting reconsideration for this prescription.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveMacrobid capsules.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta.
You asked the Plan to pre-approve Neulasta. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Neulasta. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has recurrent colorectal cancer. The submitted documents do not indicate that the enrollee has had previous episodes of neutropenic fever. The submitted white blood counts and absolute neutrophil counts (ANC) have been normal. Neulasta is indicated in patients with non-myeloid malignancies receiving myelosuppressive chemotherapy with a clinically significant incidence of febrile neutropenia for prophylaxis. The NCCN Guidelines Version 2.2020 Management of Neutropenia do not list infusional 5FU or Avastin as having high or intermediate risk of neutropenic fever. Therefore, the documentation does not support that Neulasta is medically reasonable and necessary, nor that it is safe and effective 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 Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 the drug testing services provided on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM).
You asked the Plan to pre-approve the Continuous Glucose Monitor. You say that the CGM is medically
necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that for a CGM to be covered, the enrollee must be
insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered continuous
subcutaneous insulin infusion (CSII) pump.
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 Continuous Glucose Monitor. Our
reviewer says that the CGM is not medically necessary. Our physician reviewer found the enrollee is only
injecting insulin once daily. The record does not show a medical reason why the enrollee cannot use a
traditional glucometer.
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 Continuous Glucose Monitor have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation rendered on October 31, 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 93010 is 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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010 is not supported in the medical record. Specifically, there is no documentation of interpretation and report of an EKG. 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 electrocardiogram (EKG) interpretation rendered on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee and wrist-hand orthosis provided to the enrollee on December 11, 2019.
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 according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the enrollee and the ordering physician.
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: HCPCS L1833: Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf HCPCS L2397: Addition to lower extremity orthosis, suspension sleeve HCPCS L3916: Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf 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 the enrollee is reported to have right knee pain and left wrist pain. No detailed history, recent injury or surgery, associated symptoms, review of systems or physical examination, including weakness and/or deformity, has been documented. There is no evidence of diagnostic evaluation (i.e. x-rays) or prescription therapy provision/response (i.e. prescription meds, injections, PT/OT).
Therefore, the documentation does not support the medical necessity or reasonableness of the provided service. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for a knee and wrist-hand orthosis provided to the enrollee on December 11, 2019.