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

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the pelvis.
You asked the Plan to pre-approve a CT scan of the pelvis. You say that the services are 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 CT 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 CT scan of the pelvis. Our reviewer
says that the services are medically necessary. Our physician reviewer found recently the enrollee's prostatespecific
antigen (PSA) rose from 8.2 to 11. A CT of the pelvis is reasonable to assess for regional lymph nodes,
etc.
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 CT scan of the pelvis have been met. Therefore, we decided that the Plan has
to pre-approve a computed tomography (CT) scan of the pelvis.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on
July 14, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you should not have to pay the
copayment for the ER visit because it was needed due to erroneous lab services. The Plan denied your request.
The Plan says you were charged this copayment 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 $65
copayment for emergency room visits.
You have been asked to pay a $65 copayment for the ER visit. This copayment applies regardless of the reason
for the visit. 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 the emergency room (ER) visit you had on
July 14, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve anesthesia for a nerve block and injection procedure.
You asked the Plan to pre-approve anesthesia for a nerve block and injection procedure. You say that the
services are necessary. The Plan denied your request. The Plan says that based on the documentation provided,
coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that local anesthesia or minimal conscious sedation may
be appropriate. Use of moderate sedation and Monitored Anesthesia Care (MAC) is usually unnecessary.
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 anesthesia for a nerve block and
injection procedure. Our reviewer says that the services are not medically necessary. Our physician reviewer
found the review has determined that you have a diagnosis, conditions, and/or symptoms that meet the
Medicare criteria for coverage of MAC. Although MAC is not considered the standard of care in the treatment
of your condition, it is medically reasonable for you to have the requested anesthesia services, as requested.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of anesthesia for a nerve block and injection procedure have been met. Therefore,
we decided that the Plan has to pre-approve anesthesia for a nerve block and injection procedure.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you
had on May 25, 2021.
You asked the Plan to waive the copayment for the MRI. You say that the Plan should pay more than you for
these services. The Plan denied your request. The Plan says you were charged this copayment 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 $155
copayment for radiological diagnostic services.
You have been asked to pay a $155 copayment for the MRI. The MRI falls within the radiological diagnostic
services 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 the magnetic resonance
imaging (MRI) you had on May 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the face.
You asked the Plan to pre-approve a CT scan of the face. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan of the face. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no detail concerning physical exam, duration of symptoms or what efforts have been made to treat the enrollee's symptoms. Absent that information the medical necessity of a CT of the sinuses has not been established. 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 CT scan of the face have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the face.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on August 6, 2021.
You asked the Plan to pay for the dental services. You say that the x-ray was necessary. You say that the dentist wanted to make sure there were no issues with the tooth to be extracted due to your diagnosis. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that 1 complete series x-ray is covered every 3 plan years. The Plan also says the frequency limits have 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 and the services are not listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a complete oral evaluation and complete series x-ray that you received on October 19, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on August 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate care and does not require a transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that the enrollee was admitted to the acute care hospital for coronavirus pneumonia. There are no complex medical or nursing needs. There is no need for a 25-day stay. There are no complex wound care needs. The requested services will not change any short or long-term outcomes. The requested LTACH services medically necessary, reasonable, and appropriate for the diagnosis and condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on August 10, 2021.
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says a refraction is not
separately reimbursed as part of a routine eye exam or as part of a medical examination and evaluation with
treatment/diagnostic program.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in
connection with otherwise covered diagnosis or treatment of illness or injury.
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of
any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to
pay for an eye refraction provided on August 10, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve percutaneous implantation of neurostimulator electrodes.
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrodes. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that SCS may be covered for the relief of chronic intractable pain under specific circumstances. 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 percutaneous implantation of neurostimulator electrodes. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee meets the criteria for a SCS trial. The trial is 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 percutaneous implantation of neurostimulator electrodes have been met. Therefore, we decided that the Plan has to pre-approve percutaneous implantation of neurostimulator electrodes.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a RevoFit2 (CPT code L5999).
You asked the Plan to pre-approve the item. You say that the enrollee is currently at a K2 functional level. The
Plan denied your request. The Plan says the records did not indicate a medical need for the RevoFit2.
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. Based on this information, we decided that
Medicare rules for coverage of the item have not been met. Items billed under code L5999 can be covered by
the plan if there is a medical need for the item. The plan received additional records from your provider. These
records did not indicate a medical need for the RevoFit2. When the plan made outreach to the provider's office
to notify them of the decision, the provider confirmed the member would no longer be needing the requested
L5999 service. Therefore, we decided that the Plan does not have to pre-approve a RevoFit2 (CPT code
L5999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, abdomen and pelvis; with contrast material(s) (CPT
code 74177) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network CT scan. You say that the service is necessary. The Plan
denied your request. The Plan says there are in-network providers available who can supply the requested
service.
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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
CT, abdomen and pelvis; with contrast material(s) (CPT code 74177) to be provided by an out-of-network
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (CPT code S9338) provided to the
enrollee on May 11, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says the service is not covered as billed.
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 service have not been met. Per Medicare guidelines this code is
not a valid code for Medicare purposes as CPT code S9338 is assigned a status code I = Not valid for Medicare
purposes. Therefore, we decided that the Plan does not have to pay for home infusion therapy (CPT code
S9338) provided to the enrollee on May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injections (ESI).
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that there is no documentation of duration of benefit from prior
injection and there is no documented functional benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that epidural steroid injections
can be covered if LCD criteria has been 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 requested services are not considered medically reasonable and necessary in this case. There is no mention
of original pain scale prior to the injections. There is also no mention of time frames regarding effectiveness or
non-effectiveness. There is no mention of when the original injections were administered to judge if the 14 day
allotment has passed. The medical records are unclear in time references of previous injections. Our physician
reviewer found that your condition does not meet Medicare criteria for these services.
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 epidural steroid injections (ESI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on July 6, 2021.
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says the hearing aids were
purchased less than three years from October 18, 2018, when you received coverage for 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 aids every 3 years.
We looked at the file and the Plan's rules. The file shows that you have exceeded the maximum hearing aid
benefit as you previously received the benefit on October 18, 2018. The benefit covers hearing aids every
3 years. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been
met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair and a U-1 sealed
lead acid battery.
You asked the Plan to pre-approve a group 2 standard power wheelchair and a U-1 sealed lead acid battery.
You say that the services are necessary. The Plan denied your request. The Plan says based on the
documentation provided, coverage criteria has not been met.
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.
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 group 2 standard power wheelchair
and a U-1 sealed lead acid battery. Our reviewer says that the items are not medically necessary.
Our physician reviewer found while the enrollee may be able to safely operate a PMD, the requested group 2
standard power wheelchair with a weight capacity up to and including 300 pounds and U-1 sealed lead acid
battery exceeds the enrollee's medical need per LCD L33792.
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 group 2 standard power wheelchair and a U-1 sealed lead acid battery have
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power
wheelchair and a U-1 sealed lead acid battery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 17, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 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 G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."

We find that CPT code G0483 is not supported in the medical record. Specifically, the records provided do not show that 22 or more drug classes were tested on the date of service in question. 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 (G0483) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye exam (92004) gonioscopy (separate
procedure) (92020) scanning computerized ophthalmic diagnostic imaging (92134) provided July 26, 2021 by
an out of network provider.
You asked the Plan to pay for the vision services. You say that due to your diabetic condition, your doctor
suggested that you have your eye checked. The Plan denied your request. The Plan says enrollee's must receive
their services from an in-network provider.
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. The Plan covers these services when rendered by an in-network provider.
We looked at the file and the Plan's rules. Vision services must be rendered by an in-network provider. Based
on this information, we decided that the Plan's rules for coverage of the vision services have not been met.
Therefore, we decided that the Plan does not have to pay for comprehensive eye exam (92004) gonioscopy
(separate procedure) (92020) scanning computerized ophthalmic diagnostic imaging (92134) provided July 26,
2021 by an out of network provider