Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biopsy and injection services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the requested combination of codes is not allowed.

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 looked at the file and the rules. We find that CPT codes 64450 and 76942 were requested. CPT code 64450 is not medically necessary when billed with CPT code 76942. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve biopsy and injection services
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve UltraMIST wound therapy. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has undergone several 
wound treatments with no avail. The Plan denied your request. The Plan says medical studies have not proven 
the device is helpful for treatment of the enrollee's health problem. 
 
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. There is insufficient scientific or clinical evidence to consider this 
device as reasonable and necessary for the treatment of wounds. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve UltraMIST wound therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cardiology consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the cardiology consultation. You say that you want to be seen at a larger hospital and you are uncomfortable with the type of service of the in-network authorization. The Plan denied your request. The Plan says the provider is out-of-network.
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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the cardiology consultation to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable


We decided that the Plan does not have to pre-approve muscle and skin advancement flap closure for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that there is concern for risk of wound breakdown. 
The Plan denied your request. The Plan says that the records do not indicate that the member has abnormal 
structure of the body, congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. 
 
The Plan must follow Medicare rules. Medicare rules say that reconstructive surgery is performed on abnormal 
structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, 
involutional defects, or disease. It is generally performed to improve function, but may also be done to 
approximate a normal appearance. 
 
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. The enrollee is 
undergoing a planned neurosurgical procedure and there is a concern for wound closure. The record provided is 
insufficient to demonstrate the reconstructive nature of the procedure at this time. Our physician reviewer 
found that the enrollee's 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 muscle and skin advancement flap closure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies provided on April 22, 2021.

You asked the Plan to pay for the supplies. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the supplies provided on April 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on October 1, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim should be processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on October 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the services are available from a participating provider.

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 magnetic resonance imaging (MRI) services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on February 14, 2020.
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim should be processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that without an upper denture you are 
not able to chew your food properly, which is affecting your health and digestion. The Plan denied your 
request. The Plan says this service exceeds the maximum count allowed per period. 
 
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, maxillary partial denture (D5213) is 
limited to one procedure every five plan years. The record shows that you received a maxillary partial denture 
(D5213) on August 24, 2020 and your maxillary partial denture (D5213) benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic care to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the chiropractic care. You say that you want to continue seeing this provider because he is the best doctor for your condition. The Plan denied your request. The Plan says the provider is out-of-network.
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 the chiropractic care 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 pre-approve compression stockings identified with code A6531.
You asked the Plan to pre-approve compression stockings. You say that compression stockings are medically necessary for lymphedema. The Plan denied your request. The Plan says Medicare criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 are covered only when they are used to treat an open venous stasis ulcer. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 23, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 23, 2021, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 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 inpatient psychiatric care from October 
23, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of October 23, 2021, forward. Our physician reviewer found you do not 
require inpatient mental health treatment beyond October 23, 2021, as you were not a danger to yourself or 
others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 23, 2021, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 23, 
2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for tympanostomy (69433) provided on May 17, 2021.
You asked the Plan to pay for tympanostomy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code has a medically unlikely edits (MUE) value of 1 but 2 units were billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 69433 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of tympanostomy have not been met. Therefore, we decided that the Plan does not have to pay for tympanostomy (69433) provided on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria was not met.

The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 

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 monitor. Our reviewer says that the requested monitor is not medically reasonable or necessary. Our physician reviewer found there is no clear indication that the enrollee is taking a rapid-acting insulin that is adjusted based on blood glucose levels.

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2391), crown (D2740), and core buildup, including any pins when required (D2950) provided on June 17, 2021.
You asked the Plan to pay for the resin-based composite, crown, and core buildup. You say that you had to get another insurance and still owe $1,000.00, which is a hardship for you. The Plan denied your request. The Plan says these services are not covered expenses under your dental 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 pay for the resin-
based composite (D2391), crown (D2740), and core buildup, including any pins when required (D2950) provided on June 17, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) chiropractic manipulative treatment (98943) electrical stimulation (G0283) manual therapy techniques (97140) provided May 10, 2021 to May 13, 2021.
You asked the Plan to pay for the chiropractic services. You say that you had hurt your shoulder and lower back while moving. You went to the chiropractor right after you moved to New Jersey and had not found a primary care physician at that time. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.
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 for the outpatient office visit (99202) chiropractic manipulative treatment
(98943) electrical stimulation (G0283) manual therapy techniques (97140) provided May 10, 2021 to May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care services rendered on March 27, 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 99379 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 99379 (supervision of care of nursing facility patient, without patient present, 15-29 minutes) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the nursing facility care services rendered on March 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PUREWICK external female urine collection device.

You asked the Plan to pre-approve the PUREWICK external female urine collection device. You say that the item is medically necessary. The Plan denied your request. The Plan says you are not bed confined.

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 PUREWICK external female urine collection device have not been met. Specifically, you are able to move around with a walker. This means you are not bed confined and do not meet all criteria for this item. Therefore, we decided that the Plan does not have to pre-approve the PUREWICK external female urine collection device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (93976) provided on June 15, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 code 93976 has a bundled relationship with code 76856 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (93976) provided on June 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on 
January 30, 2020. 
 
You asked the Plan to pay for the intraoperative neuromonitoring services. You say that the recoupment for 
these services was made in error. The Plan denied your request. The Plan says the enrollee was at an inpatient 
status during the date of service, and these services are not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
Medicare rules also say that if the mobile unit is serving an entity for which another Place of Service (POS) 
code already exists, providers should use the POS code for that entity.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare coverage 
criteria for the intraoperative neuromonitoring services have not been met. Specifically, the record indicates 
that the provider was serving an entity for which another Place of Service (POS) code exists. Additionally, 
payment for these diagnostic services is made to the facility and is the responsibility of the facility to any 
vendor. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring 
services provided on January 30, 2020.