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

We decided that the Plan does not have to pre-approve a lumbar MRI (72148).
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is medically necessary. The Plan denied your request. The Plan says repeat imaging is not supported without results or prior imaging that show a clear reason for it.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 the MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found the records show that the same study or a test like it has been previously completed. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar MRI (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on December 10, 2019.
You asked the Plan to pay for train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 95999 is not supported by the medical records submitted.
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 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary procedure and payment is bundled into the payment for the approved primary neuromonitoring service. Based on this information, we decided that Medicare rules for coverage of train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on December 10, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine venipuncture and complete blood count provided on December 11, 2019.You asked the Plan to pay forthe routine venipuncture and complete blood count. You say that you were on hospice at the time of these services, but this diagnosis is unrelated to your hospice diagnosis.The Plan denied your request. The Plan says that Original Medicare is responsible for the hospice services that are related or unrelated to your hospice diagnosis.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the routine venipuncture and complete blood count provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95937) provided on October 31,
2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says train of four monitoring does not meet
the CMS guidelines of CPT code 95937.
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 record. Specifically, train of four monitoring does not
meet the CMS guidelines of CPT code 95937. It is not appropriate to bill the code for neuromuscular junction
testing for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of
the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for
train of four monitoring (95937) provided on October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee required minimal assistance of two with walking with home health aide. The enrollee required minimal to moderate assistance with transfers. The enrollee's nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee may benefit from further physical therapy, the enrollee does not require an intensive rehabilitation therapy program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for several fillings (D2392, D2330 and D2391) provided on
October 16, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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.
Review of the file show that you received several fillings (D2392, D2330 and D2391) provided on October 16,
2019. The Plan paid for two (2) fillings and you are responsible for the five (5) fillings. You do not meet the
conditions for approval of 5 additional fillings because you exceeded the number of allowed fillings for the
time period stated in your EOC. Your EOC states, there is a benefit for two (2) fillings every calendar year with
0% coinsurance. Therefore, we decided that the Plan does not have to pay for several fillings (D2392, D2330
and D2391) provided on October 16, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services provided to the enrollee on January 11, 2020.
You asked the Plan to pay for the services. You say that the denial of this claim was unjustified. The Plan denied your request. The Plan says that the codes A0428 and A0425 have not met the associated secondary diagnosis code relationship criteria.
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. The plan's denial is contradictory and unsubstantiated by the case file. The plan says the claim is being denied because of an invalid or missing diagnosis code, but does not elaborate what could be done to fix this issue. The plan also denies the claim due to an issue with the units of service. HCPCS A0428 is denied, saying the units of service should be one. The submitted claim from the provider shows the units of service as one, and the plan's submitted claim information is an internal screenshot with no information about the units billed. HCPCS A0425 is denied, stating that the units of service should represent the loaded miles. The plan has not provided what the total loaded miles were for this case, as they have not provided information on where the enrollee was transported from. Additionally, the transport company provided evidence that the services were approved from November 5, 2019 to February 2, 2020. Therefore, we decided that the Plan has to pay for ambulance services provided to the enrollee on January 11, 2020.
If 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 to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen (J8499). You asked the Plan to pre-approve the Hydrocodone-Acetaminophen. You say that the drug is medically necessary. The Plan denied your request. The Plan says this type of drug is not eligible for coverage under the Part B medical 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 Hydrocodone-Acetaminophen (J8499). Benefits for the Hydrocodone-Acetaminophen 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forelectrical stimulation (G0283) provided by a chiropractor on November 5, 2019.You asked the Plan to pay forelectrical stimulation. You say that this should be covered.The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forelectrical stimulation (G0283) provided by a chiropractor on November 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hydrocodone-acetaminophen.
You asked the Plan to pre-approve hydrocodone-acetaminophen. 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 a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 hydrocodoneacetaminophen.
Benefits for hydrocodone-acetaminophen 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on December 20, 2019. 
 
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Review of the file shows that the documentation submitted did not include an itemized Delivery Ticket indicating the billed DME supply. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee on January 15, 2020.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee on January 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical insertion of the interspinous stabilization device (22867).
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial as long term studies have demonstrated improvement for patients who underwent interspinous distraction decompression for degenerative spinal stenosis. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the device remains experimental for spine surgery. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the surgical insertion of the interspinous stabilization device (22867).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan.
You asked the Plan to pre-approve a PET scan. 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 must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 a PET scan. Our reviewer says that the documentation does not support that the requested PET scan is medically reasonable or necessary. Our physician reviewer found the enrollee has a long history of elevated prostate specific antigen (PSA) with 2 prior negative biopsies. Most recent PSA was 19.9 ng/mL on 1/2020. A prostate MRI was indeterminate due to distortion caused by prior prostatic artery embolization. MRI revealed some cystic bone lesions that were indeterminate and prostate biopsy was suggested. The enrollee does not have an indication for which an Axumin PET Scan can be covered at this time. Axumin PET Scan is indicated for men with suspected prostate cancer recurrence based on elevated blood prostate specific antigen (PSA) levels following prior treatment. The medical records do not indicate that this enrollee has had a positive biopsy for prostate cancer. Therefore, the requested services are not medically 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit for an endoscopy (99214) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you have seen the provider before and would like to use them again. The Plan denied your request. The Plan says the services are not emergent and there are 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 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 the office visit for an endoscopy (99214) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397)
provided to the enrollee on December 26, 2019.
You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the orthosis and sleeve have not been met. Documentation
submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply
code cannot be verified. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and
suspension sleeve (L2397) provided to the enrollee on December 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance tab 25mg for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says this medication is covered under Part D benefits, but the enrollee does not have Part D 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-approve Jardiance tab 25mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99202) provided on December 16, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this was not a new patient visit.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also say that Medicare interprets the phrase "new patient" to mean a patient whohas not received any professional services from the physician or physician group practice (same physician specialty) within the previous 3 years.In this case, the CPT Code Manual definition of code 99202 is " Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. 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 low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family".We find that CPT code 99202 is not supported in the medical record. Specifically, the records provided show that the enrollee was provided a new patient visit by the provider in question on December 9, 2019. This means that the services in question were provided by the same provider within 3 years of the new patient visit. This means that the enrollee was not considered a new patient for the visit on December 16, 2019, and it is inappropriate to bill CPT 99202 for an established patient visit. 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 forthe services (CPT 99202) provided on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction teeth #5, #6 (D7140) intraoral-periapical x-ray (D0220) and limited oral exam (D0140) provided January 9, 2020. You asked the Plan to pay for the dental services. You say that you are appealing the denial of dental coverage. You switched to this plan because dental coverage was offered to you. So you were surprised to not be covered for this visit. The Plan denied your request. The Plan says these services are not covered under the plan. 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 health plan contract says that any services not listed are not covered. 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 extraction teeth #5, #6 (D7140) intraoral-periapical x-ray (D0220) and limited oral exam (D0140) provided January 9, 2020.