Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the high-frequency chest wall oscillation
device (SmartVest) you received on July 22, 2021.
You asked the Plan to waive the coinsurance for the SmartVest. You say that you would like this charge
reconsidered because the SmartVest is medically necessary. The Plan denied your request. The Plan says you
were charged this coinsurance 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 20%
coinsurance for durable medical equipment.
You have been asked to pay 20% coinsurance for the SmartVest. The SmartVest falls within the durable
medical equipment benefit category. This cost sharing applies regardless of the necessity of the device. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the coinsurance for the high-frequency chest wall oscillation device
(SmartVest) you received on July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.
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 to meet criteria there must be documentation of the members
failure to respond to other noninvasive conservative measures.
The Plan must follow Medicare rules. Medicare rules say that an ESI can be covered if the enrollee has the
inability to tolerate noninvasive conservative care or medical documentation of failure to respond to four (4)
weeks of noninvasive conservative care.
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 record of
active rehabilitation, home exercise, or functional restoration program. Our physician reviewer found that your
condition does not meet criteria for coverage of 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 an epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory work provided on March 16, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says although the claim originally denied for not meeting Medicare criteria, there was no prior authorization obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for laboratory work provided on March 16, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62320) provided October 25, 2021.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. No medical records were submitted to support this service. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endosteal implants (D6010) to be provided by a
participating provider.
You asked the Plan to pre-approve an endosteal implant. You say that you cannot eat, and you do not have ant
teeth. The Plan denied your request. The Plan says the requested dental work is not a covered benefit.
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-approve
endosteal implants (D6010) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) and endodontic therapy (D3310).
You asked the Plan to pre-approve the crown and endodontic therapy. You say that you do not have the money
to cover these services out of pocket. The Plan denied your request. The Plan says these services are not
covered under your benefit 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. Therefore, we decided that the Plan does not have to pre-approve a
crown (D2751) and endodontic therapy (D3310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3020).
You asked the Plan to pre-approve foot orthotics. You say that the requested items will be attached to a covered
leg brace. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
The case record does not show that you suffer from diabetic foot disease or that you do wear a leg brace.
Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics
for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia (00170), and a dental surgery (41899) to be provided by a participating provider.

You asked the Plan to pre-approve anesthesia and a dental surgery. You say that you need this done so you can eat and smile again. The Plan denied your request. The Plan says the requested dental services are not covered benefits.

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-approve anesthesia (00170), and a dental surgery (41899) to be provided by a participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee is not safe to go home. The Plan denied
your request. The Plan says the enrollee's needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the records do not show that the enrollee has
skilled nursing needs. While he has skilled therapy needs, he does not need daily therapy services. Based on the
medical records provided, the enrollee does not require services on an inpatient basis, only in a skilled nursing
facility setting. Services in the home with home health care or in a long-term care facility on a part time basis
appear appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Transthoracic Echocardiography (93307).
You asked the Plan to pre-approve Transthoracic Echocardiography. The Plan denied your request. The Plan says Transthoracic Echocardiography is not medically necessary based on the Medicare LCD L34338.
The Plan follows Medicare rules. 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 Transthoracic Echocardiography. Our reviewer says that Transthoracic Echocardiography is not medically necessary. Our physician reviewer found that the enrollee has a history of atrial fibrillation and coronary angioplasty with stent placement. He had lived
out of state and has now established medical care with a new physician. He has had prior TTE, but the result is unknown. The previous TTE report should be obtained. Documentation at this time would not point to a change in status that would support the medical necessity of a repeat TTE. Clinical guidelines do not support repeating a TTE with no intervening change in clinical status or new signs, symptoms or physical findings. In summary, there is no supportive evidence for the medical necessity of repeat TTE in this enrollee's clinical management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Transthoracic Echocardiography have not been met. Therefore, we decided that the Plan does not have to pre-approve Transthoracic Echocardiography (93307).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network
(OON) provider on May 3, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service 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 this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on May 3,
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy rendered on July 9, 2021.
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 97010 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Billed procedure code 97010 (hot or cold packs therapy) has a status
indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for
the hot or cold packs therapy rendered on July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture with flexible base (D5225).
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says partial upper denture with flexible base is not a covered service.
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 partial upper denture with flexible base is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture with flexible base (D5225).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office consultation. You say that you need a sooner appointment then what is available in-network. The Plan denied your request. The Plan says a list of in-network providers was given to the enrollee accepting new patients within the next month.
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 an office consultation to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care after
February 12, 2022.
You asked the Plan to pre-approve the continuation of inpatient psychiatric care. You say that inpatient
psychiatric care remains medically necessary. The Plan denied your request. The Plan says the criteria for
coverage have not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the continuation of inpatient psychiatric
care. Our reviewer says that the requested continuation of inpatient psychiatric is not medically reasonable and
necessary. Our physician reviewer found that you are a 71-year-old female who was admitted to the acute
inpatient psychiatric hospitalization on February 2, 2022, with Bipolar Disorder Unspecified. Based upon
review the records provided it was not expected that you would improve in a reasonable period of time for the
dates in question as you did not have suicidal or homicidal ideation noted and denied any auditory or visual
hallucinations. You were compliant with treatment while not showing any acute threats to safety. It did not
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care
rather than a lower level of care beyond the dates in question as you did not have dangerousness to yourself or
others and were compliant with your treatment.
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 continuation of inpatient psychiatric care have not been met. Therefore, we
decided that the Plan does not have to pre-approve the continuation of inpatient psychiatric care after February
12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 out of network dentist visits.
You asked the Plan to pre-approve out of network dental visits. You say that when you have used dentists that
accept your insurance. You also say that you do not want to change dentists. The Plan denied your request. The
Plan says dental services are only covered when received by a participating provider.
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 out of network dental
visits are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve 3 out of network dentist visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MSH2 gene analysis coded 81295, the MSH6 gene
analysis coded 81298, the CACNA1A gene analysis coded 81185, the hereditary breast cancer-related
disorders gene analysis panel coded 81432, and the unlisted molecular pathology procedure coded 81479
provided on August 29, 2020.

You asked the Plan to pay for the MSH2 gene analysis, the MSH6 gene analysis, the CACNA1A gene analysis,
the hereditary breast cancer-related disorders gene analysis panel, and the unlisted molecular pathology
procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The
Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes
81295 and 81298 are column II codes to column I code 81432. This claim has not been billed with an
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been
met.

We find that CPT codes 81185, 81479, and 81432 are not supported in the medical record. Specifically, the
documentation did not support CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg,
spinocerebellar ataxia) gene analysis; full gene sequence; therefore, code 81185 cannot be verified. When
Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel and is not currently
satisfactorily described by any existing CPT code, providers should only use one unit of code 81479 for the
entire bundled multi-test panel. In addition, the appropriate DEX Z code identifier should be entered adjacent
in the comment/narrative field for the test. Review of the file shows that these services were billed unbundled
into separate codes. 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 MSH2 gene analysis coded 81295, the MSH6
gene analysis coded 81298, the CACNA1A gene analysis coded 81185, the hereditary breast cancer-related
disorders gene analysis panel coded 81432, and the unlisted molecular pathology procedure coded 81479
provided on August 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62320) provided July 5, 2021.
You asked the Plan to pay for the injections. You say that the injections were medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. No medical records were provided to support this service. Based on
this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore,
we decided that the Plan does not have to pay for injections (62320) provided July 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mechanochemical endovenous ablation to be provided
by an out-of-network (OON) provider.
You asked the Plan to pre-approve a mechanochemical endovenous ablation. You say that there are no
providers close to the enrollee to provide the special type of treatment needed. The Plan denied your request.
The Plan says a list of in-network providers was given to the enrollee that are close to the enrollee's home
address.
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. Please note, the Plan has indicated that there are in-network
providers within a reasonable distance. Therefore, we decided that the Plan does not have to pre-approve a
mechanochemical endovenous ablation to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic services coded as 98940 and 98941.
You asked the Plan to pre-approve the chiropractic services. You say that you twisted your jaw to the point
where it is inflamed. You are experiencing pain from your ears down to your hip. These adjustments have been
allowing you to get a better sleep but you are still dealing with the pain. The Plan denied your request. The Plan
says this service is not covered under the Plan benefits.
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 pre-approve the chiropractic services coded as 98940 and 98941.