Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299). 
 
You asked the Plan to pre-approve direct skilled nursing services of an RN. You say that you need to continue 
wound care at home three times per week. The Plan denied your request. The Plan says the records provided do 
not show the medical need for in-home skilled nursing care. 
 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 direct skilled nursing services of an RN. 
Our reviewer says that you do not meet the criteria for coverage for the direct skilled nursing services of an 
RN. Our physician reviewer found nursing states that you have had change in status of wound and previous 
visits were approved on the basis that you would have physician re-evaluation. Our reviewer found that the 
documentation does not support the change in status of wound, thus 9 additional home health visits are not 
medically appropriate at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of direct skilled nursing services of an RN have not been met. Therefore, we 
decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tysabri (J2323). 
 
You asked the Plan to pre-approve Tysabri. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for Tysabri. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Tysabri. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Tysabri. Our physician reviewer found there is no indication 
that the enrollee has tried and failed the required drug. Our reviewer also found that there is no indication that 
the Plan's required drug would likely be less effective and/or likely have adverse effects for 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 Tysabri have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Tysabri (J2323).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right knee genicular nerve radiofrequency ablation 
(64640). 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that you have had many injections, 
and pain medications and nothing has worked to control the pain. 
 The Plan denied your request. The Plan says the records received did not show that radiofrequency ablation 
treatment is 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 radiofrequency ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was being treated for pain in the right knee. The enrollee 
presented with knee pain and has had a recent injection with an orthopedic surgeon. The exam revealed 
tenderness to palpation of the lateral and medial joint lines. However, detailed documentation is not reasonably 
evident regarding diagnostic imaging studies that corroborate the pathology of the right knee. The LCD does 
not recommend this procedure without a comprehensive assessment of the source of the pain and treatment of 
any underlying pathology. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the medical records provided do not 
meet the medically necessary requirements for Medicare Coverage. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve right knee genicular nerve radiofrequency ablation (64640).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the hydrophilic contact lenses (V2520) provided on 
May 31, 2022. 
 
You asked the Plan to pay more for the hydrophilic contact lenses. You say that the lenses prescribed are 
specific to your deficit due to a stroke. The Plan denied your request. The Plan says the maximum calendar 
year benefit for Vision Hardware has been reached and paid. 
 
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 up to $150 every year for vision hardware. 
 
We looked at the file and the Plan's rules. The record shows that you exhausted your vision hardware allowance 
of $150 on this date of service, and you are responsible for the remaining amount. Based on this information, 
we decided that the Plan's rules for coverage of the hydrophilic contact lenses have not been met. 
 
 
 
 
  
 
 Therefore, we decided that the Plan does not have to pay more for the hydrophilic contact lenses (V2520) 
provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two retainer crowns (D6740) and a porcelain or ceramic 
pontic (D6245) provided on June 9, 2022. 
 
You asked the Plan to pay for two retainer crowns (D6740) and a porcelain or ceramic pontic (D6245). You 
say that this was a very necessary procedure and in no way cosmetic. The Plan denied your request. The Plan 
says these services are an excluded benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. . Retainer crowns (D6740) and 
porcelain or ceramic pontics (D6245) are excluded from this benefit. 
 
 
  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 two 
retainer crowns (D6740) and a porcelain or ceramic pontic (D6245) provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two problem focused limited oral evaluations (D0140 x2) 
and to pay more for the surgical extraction (D7210) provided on April 19, 2022, and June 6, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluations or pay more for the surgical 
extraction. You say that you would like to be correctly reimbursed for these services. The Plan denied your 
request. The Plan says your benefit for the problem focused limited oral evaluations has already been 
exhausted. The Plan also says that the cost share for the surgical extraction was applied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the problem focused limited oral evaluations (D0140) was exhausted on date of service 
February 2, 2022. The contract also clearly states that you are responsible for a 50% coinsurance for surgical 
extractions (D7210). Therefore, we decided that the Plan does not have to pay for the two problem focused 
limited oral evaluations (D0140 x2) and to pay more for the surgical extraction (D7210) provided on April 19, 
2022, and June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit, and an office visit provided on June 
10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an annual wellness visit and an office visit. You say that you were told the 
provider was in-network. The Plan denied your request. The Plan says you must receive your care from a 
network 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 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 had network providers 
available who could have provided the items/services at issue in this appeal. 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. 
Therefore, we decided that the Plan does not have to pay for an annual wellness visit, and an office visit 
provided on June 10, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala Trio Device. 
 
You asked the Plan to pre-approve the requested services. You say that the device aids in the temporary relief 
of hand tremors. The Plan denied your request. The Plan says the device is unproven. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a diagnosis of essential tremor. A single-arm, open-label study published 
in November 2020 suggested that Transcutaneous Afferent Patterned Stimulation (TAPS) therapy can reduce 
hand tremor for one hour in essential tremor patients. "These results suggest that TAPS can provide reductions 
in upper limb tremor symptoms for at least 1 h post-therapy in some patients, which may improve patients' 
ability to perform tasks of daily living. The documentation does not support that the requested Cala Trio nerve 
stimulator device is medically reasonable and necessary for the enrollee in this case. Rather, the device would 
be considered experimental and investigational at this time. 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Cala Trio Device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for IV therapy and Part B drug injections 
provided from May 17, 2022, to May 19, 2022. 
 
You asked the Plan to waive the coinsurance for IV therapy and Part B drug injections. You say that you 
should not be responsible to pay this. The Plan denied your request. The Plan says this cost sharing was 
charged 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 20% 
coinsurance for the total cost for all other Medicare Part B drugs, including chemotherapy drugs.  
 
 
 
 You have been asked to pay $1,667.18 for IV therapy and Part B injections. This item/service falls within the 
Medicare Part B drugs 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 coinsurance for IV therapy 
and Part B drug injections provided from May 17, 2022, to May 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2022, to February 25, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that S9328 is billed for each 24-hour period the 
enrollee is provided with implanted pump pain management infusion. You say that S9328 is payable, and the 
claims should be reprocessed for payment. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2022, to February 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on June 
3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 30, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on June 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2022. 
 
You asked the Plan to pay for the services provided. You say that all services were rendered properly. The Plan 
denied your request. The Plan says the records do not contain documentation to support the coding. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT codes 87491 and 87591 are not supported in the medical record. Based on this information, 
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on February 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service April 19, 
2022. 
 
You asked the Plan to pay for procedure code 71045. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 71045 is bundled into 
payment for code 71111. 
 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 71045 
is a column II code to column I code 71111. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 71045 billed for date of service April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third level facet joint injection. 
 
You asked the Plan to pre-approve a third level facet joint injection. You say that a third level facet joint 
injection is medically necessary. The Plan denied your request. The Plan says a third level facet joint injection 
does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 third level facet joint injection. Our 
reviewer says that a third level facet joint injection is not medically necessary. Our physician reviewer found 
that the Medicare LCD limits medial branch blocks to two levels at a session. A third level is considered not 
medically reasonable or 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 a third level facet joint injection. have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a third level facet joint injection.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the somatosensory testing (95938) provided on April 26, 
2022. 
 
You asked the Plan to pay for the somatosensory testing. The Plan denied your request. The Plan says the use 
of short-latency somatosensory evoked potentials is not medically reasonable and necessary for intraoperative 
testing during carotid endarterectomy.  
The Plan follows Medicare rules. Medicare rules say that SSEPs are used to evaluate the more proximal 
segments of nerves and the integrity of the central somatosensory pathways when slowing of conduction 
through the brain and/or brainstem, spinal cord, and/or peripheral nerves is suspected, including the conditions 
listed in the Medicare rules sections of this letter. 
 
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 somatosensory testing. Our reviewer 
says that this service does not meet the criteria for coverage. Our physician reviewer found the enrollee is noted 
to have carotid stenosis. This is not an indication for which the applicable LCDs readily support the use 
of/provision of somatosensory evoked potentials (SSEP) in a diagnostic modality. Our reviewer found that 
furthermore, the LCD states that intraoperative SSEPs are only covered for use in intraoperative testing during 
spinal surgeries in which there is risk of additional nerve or spinal cord injury. Our physician reviewer also 
found that this would ultimately not meet the requirements of the LCD for coverage at this time. 
 
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 somatosensory testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the somatosensory testing (95938) provided on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-intravenous conscious sedation (D9248) provided on 
April 6, 2022. 
 
You asked the Plan to pay for dental services. You say that the provider had issues with administering 
intravenous (IV) sedation. The Plan denied your request. The Plan says this service is not covered under your 
Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested non-intravenous 
conscious sedation are not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for non-intravenous conscious sedation (D9248) provided on April 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789-59) provided on March 3, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the documentation does not support 
separate payment for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, we find that the testing described by the billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for the laboratory services (83789-59) provided on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 24, 2021, billed 
with codes 81227, 81226, 81230, 81240, 81241, 81335 and 81291. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare billing regulations. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 24, 2021, billed with codes 81227, 81226, 81230, 81240, 81241, 81335 and 81291.