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

We decided that the Plan does not have to pay for train of four testing (95999) provided on August 20, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied
your request. The Plan says payment of 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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code
95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not
a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures.
Based on this information, we decided that Medicare rules for coverage of train of four testing have not been
met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on
August 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the implantable neurostimulator pulse generator coded
L8687 and the insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver
services coded 64590 provided on January 3, 2018.
You asked the Plan to pay for the implantable neurostimulator pulse generator and the insertion or replacement
of peripheral or gastric neurostimulator pulse generator or receiver 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
supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes L8687 and 64590 are not supported in the medical record. Specifically, the operative
report did not include documentation of a dual array rechargeable implantable neurostimulator pulse generator,
including extension; therefore, code L8687 cannot be verified. Also, the operative report did not include
documentation of an insertion or replacement of peripheral or gastric neurostimulator pulse generator or
receiver, direct or inductive coupling; therefore, code 64590 cannot be verified. Based on this information, we
decided that Medicare rules for coverage of the implantable neurostimulator pulse generator and the insertion
or replacement of peripheral or gastric neurostimulator pulse generator or receiver services have not been met.
Therefore, we decided that the Plan does not have to pay for the implantable neurostimulator pulse generator
coded L8687 and the insertion or replacement of peripheral or gastric neurostimulator pulse generator or
receiver services coded 64590 provided on January 3, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator provided on January 7, 2020.
You asked the Plan to pay for the oxygen concentrator. You say that the enrollee wants to continue to use you
for oxygen supplies. The Plan denied your request. The Plan says the physician order was not written by the
provider from the latest office visit and the readings are from 2002.
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient
must have tried other alternative treatments without complete success.
We looked at the file and Medicare rules. There is no valid physician order or current documentation
supporting medical necessity. Based on this information, we decided that Medicare rules for coverage of the
oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for the
oxygen concentrator provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on December 18, 2019.
You asked the Plan to pay for this service. You say that the reason for the repeat of this service was an accident
that occurred on December 7, 2019 that resulted in a head injury. The Plan denied your request. The Plan says a
routine eye exam is limited to coverage once every 12 months. The allowable benefit has been exceeded.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of this service have not been met. Specifically, you have exceeded the allowable benefit as you
previously received this service on October 3, 2019 from a different provider. Therefore, we decided that the
Plan does not have to pay for the eye refraction (92015) provided on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forwrist hand orthosis (L3916) provided January 31, 2020.You asked the Plan to pay forthe orthosis. You say that please see the attached medical records which prove the medical necessity of the items and process the claim for payment.The Plan denied your request. The Plan says the services are not supported in the medical records received.
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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the enrollee in this case, as there is no documentation of a wrist problem, nor a physical examination of the wrist.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay forwrist hand orthosis (L3916) provided January 31, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe four osseous surgeries.You asked the Plan to pre-approvethe osseous surgeries. You say that you are in severe pain and have discomfort with your gum and teeth. You also say that you cannot afford the procedure.The Plan denied your request. The Plan says your dental plan does not provide coverage for osseous surgery.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe four osseous surgeries
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided to the enrollee from
January 17, 2019, to December 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim processed
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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $20 copayment for each Medicare-covered chiropractic visit. The rules also say that the only
chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation if the
subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate
treatment.
Review of the file shows that the enrollee was provided three covered chiropractic services (98940, 98941)
from April 3, 2019, to December 5, 2019. The enrollee has been asked to pay a $20 copayment for each of the
services, totaling $60. The services fall within the chiropractic care benefit category. This means that the
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
The enrollee also received non-covered chiropractic services (99201, 99199) on January 17, 2019, and April 4,
2019. The records show that these services were not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the chiropractic services provided to the enrollee from January 17, 2019,
to December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two prophylaxes, amalgam, immediate maxillary denture, and mandibular partial denture provided from January 2, 2019 to July 8, 2019 by an OON provider.
You asked the Plan to pay for the prophylaxes, amalgam, immediate maxillary denture, and mandibular partial denture. You say that you have been seeing this provider since you were a teenager. The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that prior authorization was not obtained.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the two prophylaxes, amalgam, immediate maxillary denture, and mandibular partial denture provided from January 2, 2019 to July 8, 2019 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 6, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 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 payfor laboratory services provided on January 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve echocardiography services.
You asked the Plan to pre-approve the echocardiography services. You say that the requested echocardiography
services are medically necessary. The Plan denied your request. The Plan says the guidelines to support cardiac
imaging stress test services have not been met. The Plan says that the ECG is uninterpretable for assessment of
ischemia.
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 echocardiography services. Our
reviewer says that echocardiography services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee has some coronary risk but no symptoms, no cardiac physical
exam abnormalities and no ischemic electrocardiographic changes. In this circumstance the documentation
does not support the medical necessity for stress testing. Screening stress tests have not been shown to improve
cardiac outcome, even in high risk patients. Furthermore, if stress testing were indicated, the enrollee's
electrocardiogram is interpretable and there is documentation to indicate the patient would be unable to
ambulate for a standard treadmill electrocardiogram test.
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 echocardiography services have not been met. Therefore, we decided that
the Plan does not have to pre-approve echocardiography services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the service is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 an MRI of the lumbar spine. Our reviewer says that the service is medically necessary. Our physician reviewer found you have a known history of at least one and possibly 2 malignant diagnoses. An attempt had been made at physical therapy (PT) but was unable to complete. You have had sacroiliac (SI) joint injections. MRI of the lumbar spine is reasonable and indicated given your symptoms especially the weakness in your lower extremities. The prior history of malignancy and the weakness serve as red flags in this case and provide a valid indication for proceeding with MRI absent a completion of a 6 week trial of PT. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the fourteen crowns (D2740 x14), four prefabricated post and cores in addition to crowns (D2954 x4), four periodontal scaling and root planings (D4341 x4), endodontic therapy (D3330), diagnostic procedure (D0999), custom fabricated abutment (D6057), and abutment supported porcelain fused to metal crown (D6061).
You asked the Plan to pre-approve the crowns, prefabricated post and cores, scaling and planings, endodontic therapy, diagnostic procedure, custom fabricated abutment, and abutment supported porcelain fused to metal crown. You say that you never asked the initial provider to do all the work to your mouth. You also say that the work provided by the initial provider needs to be redone. The Plan denied your request. The Plan says these services are not covered under your 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. 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 Plan says that these dental services are covered under the dental platinum rider, but your plan currently does not have this rider. Therefore, we decided that the Plan does not have to pre-approve the fourteen crowns (D2740 x14), four prefabricated post and cores in addition to crowns (D2954 x4), four periodontal scaling and root planings (D4341 x4), endodontic therapy (D3330), diagnostic procedure (D0999), custom fabricated abutment (D6057), and abutment supported porcelain fused to metal crown (D6061).
Your complaint about your dissatisfaction with the initial provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage for a continuous positive airway pressure device (CPAP) (E0601) and CPAP humidifier, heated (E0652).
You asked the Plan to pre-approve the CPAP device and humidifier. You say that you need the device because you stop breathing in your sleep and it also helps you to not wake up with a very bad headache. The Plan denied your request. The Plan says this does not meet the medical necessity critera.
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 CPAP device and humidifier. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the compliance download provided for use only showed usage on 4 or more hours per night for 22.2% of nights in a 30 day period. This would not have met the LCD requirements for continued coverage. Therefore continued use of the PAP device is not eligible for coverage. 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 CPAP device and humidifier have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage for a continuous positive airway pressure device (CPAP) (E0601) and CPAP humidifier, heated (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered outside of the United States from
December 22, 2019 to December 27, 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 the services were not urgent or emergent and are not covered.
The Plan must follow Medicare rules. The rules say that Medicare generally does not cover items and services
furnished outside of the United States.
We looked at the file and Medicare rules. The file shows that you received services outside of the United
States. The file shows that you pre-paid for the services on August 9, 2019 and traveled outside of the United
States with a known need for dialysis. Therefore, we decided that the Plan does not have to pay for the services
rendered outside of the United States from December 22, 2019 to December 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to theenrollee on November 25, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation submitted did not include a Proof of Delivery and/or a Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on November 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from May 1, 2019, toMay 20, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these 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 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 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 forthe medical services provided to the enrollee by an out-of-network provider from May 1, 2019, to May 20, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional eight home health physical therapy visits
for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan
denied your request. The Plan says 10 of the 18 visits can be approved for this time frame.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional visits. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the records do not show that skilled therapy services are required to
effectively provide treatment, care, and/or services in order to improve your level of function, or to
establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. Your
current functional level and approved 10 visits should be sufficient to continue to work on her functional
deficits and safely transition to an independent home exercise program. The original 18 requested therapy
sessions are excessive and without evidence of a need for additional therapy or the outcome of the 10 approved
therapy sessions the request for 8 more skilled PT sessions is 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 the additional visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve an additional eight home health physical therapy visits for the enrollee.