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

We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on September 27, 2021.
You asked the Plan to pay for the therapeutic or diagnostic injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the medical necessity of the service billed.
The Plan must follow Medicare rules. Medicare rules say that the procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic or diagnostic injection have not been met. Specifically, the medical records submitted are unsigned and do not document the pre and post percent of pain relief achieved immediately post-injection.
Therefore, we decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on September 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abiraterone acetate.
You asked the Plan to pre-approve Abiraterone acetate. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says Abiraterone Acetate is not covered under your Medicare
Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Abiraterone acetate.
Benefits for Abiraterone acetate may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says a shower chair is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the extractions (D7140 x 3), and
consultation provided from October 15, 2021, to October 19, 2021.
You asked the Plan to pay the in network rate for the dental services. You say that you were told this provider
was in network. The Plan denied your request. The Plan says the provider in this case is out of network. The
Plan also says that dental services received out of network are not covered.
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 extractions are listed as covered there is an 80% coinsurance for each covered service that you receive out of network. Additionally, the
consultation is not among those covered under this benefit, regardless of the provider's network status.
Therefore, we decided that the Plan does not have to pay the in network rate for the extractions (D7140 x 3),
and consultation provided from October 15, 2021, to October 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
You asked the Plan to pre-approve the Vertiflex Superion Spacer device. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says this device remains unproven and not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Vertiflex Superion Spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex Superion Spacer device have not been met.
Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services.
You asked the Plan to pay for the SNF services. You say that you would like reconsideration because the requested SNF services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the SNF services.
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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services you received on September 1, 2021.
You asked the Plan to pay for the acupuncture services. You say that acupuncture treatments are part of your
self care and it allows you to manage your neck issues with very little medication. You believe the Plan should
permit you to continue to receive these services. The Plan denied your request. The Plan says you have
exhausted your acupuncture benefit for the year. Under your plan, you are permitted 8 acupuncture visits per
year for non-chronic low back pain issues. The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case. Under the Plan's rules, you are entitled to 8 acupuncture sessions per year for
non-CLBP conditions.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, you have already received 8 covered acupuncture
visits for your neck issues in 2021. Therefore, we decided that the Plan does not have to pay for acupuncture
services you received on September 1, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on September 14, 2021.
You asked the Plan to waive the copayment for laboratory testing. You say that there is no copay if lab services are performed as part of an office visit. The Plan denied your request. The Plan says the copayment applied was correct.
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 $10 copayment for Medicare-covered outpatient diagnostic tests.
You have been asked to pay a $10 copayment for laboratory testing. Laboratory testing falls within the outpatient diagnostic tests and therapeutic services and supplies 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 laboratory testing provided on September 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatry services you received on October 4, 2021.
You asked the Plan to pay for the psychiatry services. You say that your existing psychiatrist retired, so you found a new provider. This new provider does not file insurance claims. You believe that this claim should be paid. The Plan denied your request. The Plan says you received these services from a provider who has opted out of Medicare, so they are not covered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychiatry
services you received on October 4, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered antibiotic drugs you received in the
emergency room on October 7, 2021.
You asked the Plan to pay for the self-administered drugs. You say that the emergency room doctor prescribed
Fosfomycin for your bladder infection. This drug worked for you, so the Plan should cover it. The Plan denied
your request. The Plan says these drugs are not covered under your medical benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered antibiotic
drugs you received in the emergency room on October 7, 2021. Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl.
You asked the Plan to pre-approve Fentanyl. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Fentanyl is not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fentanyl.
Benefits for Fentanyl may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xelpros Emu 0.005%.
You asked the Plan to pre-approve Xelpros Emu 0.005%. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says Xelpros Emu 0.005% is not covered under the
enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xelpros Emu 0.005%. Benefits for Xelpros Emu 0.005% may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on October 1, 2021.
You asked the Plan to pay for the shingles vaccine. You say that you did not know that you had to go to a
pharmacy to get this. The Plan denied your request. The Plan says the shingles vaccine is not covered under
your medical benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine.
The Plan contract explicitly states that the shingles vaccine is only covered under your Part D benefits, not
under your medical benefits. Therefore, we decided that the Plan does not have to pay for the shingles vaccine
you received on October 1, 2021.
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the drug testing services (G0483) provided on April 19, 2021.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says that the member's claims history shows that
this exact service was billed on the same date.
The Plan must follow Medicare rules. Medicare rules say that an MUE for a Healthcare Common Procedure
Coding System (HCPCS)/Current Procedural Terminology (CPT) code is the maximum number of units of
service under most circumstances allowable by the same provider for the same enrollee on the same date of
service.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have been met. The documentation supports that another unit of G0483
was billed by a different laboratory. The MUE does not apply to separate billing providers. Therefore, we
decided that the Plan has to pay for the drug testing services (G0483) provided on April 19, 2021.
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 pay for foot orthotics provided on September 7, 2021.
You asked the Plan to pay for foot orthotics. 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.
Records show that you do not suffer from diabetic foot disease, and you do not 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 pay for foot orthotics provided on September 7,
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 77003 billed for date of service August 10,
2021.
You asked the Plan to pay for procedure code 77003. You say that this was a separate service and you have
appended the -59 modifier to the claim. The Plan denied your request. The Plan says procedure code 77003 is
an add-on code and it was not billed with an acceptable primary procedure code.
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
procedure code 77003 is an add-on code and has not been billed with an appropriate primary procedure code.
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan
does not have to pay for procedure code 77003 billed for date of service August 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on
September 6, 2021.
You asked the Plan to pay for the therapeutic or diagnostic injection. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation
submitted does not support the medical necessity of the service billed.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have
been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the therapeutic or diagnostic injection have not been met. Specifically, the documentation
submitted does not include any medical records. There is insufficient information to determine if Medicare
criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the
therapeutic or diagnostic injection (62320) provided on September 6, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electroconvulsive therapy (CPT code 90870), for the
enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says the enrollee's mood has improved, they are not a danger to themselves or others, they are
able to care for themselves and their daily needs, and they are not having any side effects from treatment that
require hospital care. The Plan states this treatment can be done on outpatient basis and can be safely treated in
a different setting such as outpatient electroconvulsive therapy.
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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this enrollee has been stabilized where they have no suicidal or homicidal thoughts. The
enrollee had no intrusive thoughts. The enrollee had been compliant with treatment and medications. Based on
the information provided, this enrollee does not meet criteria for continued treatment on an inpatient basis for
use of Electroconvulsive Therapy (ECT) but could be treated on an outpatient basis. 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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve electroconvulsive therapy (CPT code 90870), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable unilateral partial denture - one piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary (D5282).

You asked the Plan to pre-approve an upper removable unilateral partial denture. You say that this service is necessary. The Plan denied your request. The Plan says this service is not covered under your 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 a removable unilateral partial denture - one piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary (D5282).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered for use as bi-level pressure.
The Plan must follow Medicare rules. Medicare rules say that ventilators used for bi-level positive airway
pressure (BiPAP) are denied.
We looked at the file and Medicare rules. The file shows that the ventilator is being requested for BiPAP use.
Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service July 26,
2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly so they
should be paid. The Plan denied your request. The Plan says the medical records do not support payment for
this service.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain
documentation requirements must be met. The documentation must include a procedure report that clearly
documents the indications and the medical necessity for the blocks along with the pre and post percent pain
relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record
does not include a notation of the percent of pain relief achieved either before or after the injection. Therefore,
we decided that the Plan does not have to pay for procedure code 62320 billed for date of service July 26, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Novolog.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Novolog.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.