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

 
We decided that the Plan does not have to pay for the Octagam (J1568) and administration (G0068) provided 
on June 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the infusion services. You say that the services should be covered. The Plan 
denied your request. The Plan says the enrollee's primary care physician (PCP) did not refer them for the 
service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 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 the Octagam (J1568) and administration (G0068) provided on 
June 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 95886-26 (x2), 95955-26, and 95911-26 billed for date 
of service March 18, 2022. 
 
You asked the Plan to pay for codes 95886-26 (x2), 95955-26, and 95911-26. You say that these services were 
medically necessary and billed correctly. The Plan denied your request. The Plan says the medical records do 
not support the billing of codes 95886-26 (x2), 95955-26, and 95911-26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 In this case, the CPT Code Manual definition of code 95886 is Needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels. The 
CPT Code Manual definition of code 95955 is Electroencephalogram (EEG) during non-intracranial surgery 
(eg, carotid surgery). The CPT Code Manual definition of code 95911 is Nerve conduction studies; 9 - 10 
studies. 
 
We asked our coder 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 codes 95886-26 (x2), 95955-26, and 95911-26. Our reviewer 
says that codes 95886-26 (x2), 95955-26, and 95911-26 are not supported in the medical record. Our reviewer 
found for code 95886, per CPT code description " done with nerve conduction, amplitude and latency/velocity 
study".  Nerve conduction studies are not included in procedure report; therefore, this procedure cannot be 
verified. For code 95955, the procedure report does not include documentation of additional 
electroencephalogram (EEG) during non-intracranial surgery. Additional EEG was not found in procedure 
report. For code 95911, the procedure report describes pedicle testing, which would not be reported with nerve 
conduction, amplitude and latency/velocity study.  Therefore, this procedure cannot be verified, as nerve 
conduction studies are not documented in the procedure report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 95886-26 (x2), 95955-26, and 95911-26 have not been met. Therefore, 
we decided that the Plan does not have to pay for codes 95886-26 (x2), 95955-26, and 95911-26 billed for date 
of service March 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you would like your request for 
additional transportation to be approved. The Plan denied your request. The Plan says you have taken 62 trips, 
and have 0 trips remaining. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 60 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and progressive lens provided by an out-of-
network provider on July 14, 2022. 
 You asked the Plan to pay for the frames and the progressive lens. You say that you do not believe you should 
have a copayment because you paid the full amount when you submitted the original reimbursement request. 
You say that the Plan should make an exception. The Plan denied your request. The Plan says the claim was 
paid correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services, and you are responsible for a 10% coinsurance for the out-of-network 
covered services. 
 
We looked at the file and the Plan's rules. Specifically, you have been asked to pay 10% of the claim total. The 
claim total was $690.94. ($690.94 x 10% = $69.10). (690.94 - $69.10 = 621.84). The record shows you were 
reimbursed $621.84. Based on this information, we decided that the Plan's rules for coverage of the frames and 
the progressive lens have not been met. Therefore, we decided that the Plan does not have to pay for the frames 
and progressive lens provided by an out-of-network provider on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-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 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 office visit provided on July 1, 2022, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 18, 2022 billed with 
codes 81238, 81407, 81408, 81410 and 81414. 
 
You asked the Plan to pay for the genetic testing billed. You say that you have attached the medical records for 
this enrollee. Kindly review and process the claim towards payment. The Plan denied your request. The Plan 
says service not covered by Medicare. 
 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 
January 18, 2022 billed with codes 81238, 81407, 81408, 81410 and 81414.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) stay from September 8, 
2022, forward. 
 You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says you do not meet the 
health condition for a continued stay past September 7, 2022. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a skilled nursing facility (SNF) stay from September 8, 2022, forward.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) implant trial. 
 
You asked the Plan to pre-approve an SCS implant trial. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific 
criteria are met. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an SCS implant trial. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation in the 
record of the results of these evaluations to determine if there are other treatments available for treatment of the 
enrollee's pain. The review has determined that the enrollee does not meet the coverage criteria detailed in the 
NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an SCS implant trial have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator (SCS) implant trial.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says this is not medically necessary, and a lower level of care may be offered. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency taxi transportation to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve non-emergency taxi transportation to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
non-emergency taxi transportation to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve bone replacement graft for ridge preservation. You say that the service is 
necessary. The Plan denied your request. The Plan says the requested service 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 Plans 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 bone 
replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup (D2950) and a porcelain crown (D2751) 
provided on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel that the Plan should have partially 
covered the services you received. The Plan denied your request. The Plan says the claim was processed 
correctly. The Plan says that the core buildup service is not a covered expense under your dental benefit 
package. The Plan denied this part of the claim. Additionally, the Plan's Explanation of Benefits processed on 
July 29, 2022, and clearly shows that the Plan paid for their portion of the porcelain crown. You are responsible 
for 70 percent of the allowed amount, leaving the Plan responsible for only 30 percent (Allowed amount = 
$602  30% Plan responsibility = Plan paid $180.60). 
 
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 core buildup is not 
among those covered under this benefit. The Plans cost-sharing rules for the porcelain crown must be 
followed. You are responsible for understanding and complying with the contract rules. Therefore, we decided 
that the Plan does not have to pay for a core buildup (D2950) and a porcelain crown (D2751) provided on July 
18, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ultra Voice Plus System. 
 
You asked the Plan to pre-approve an Ultra Voice Plus System. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan follows Medicare rules. Medicare rules say that speech generating devices are covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an Ultra Voice Plus System. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the clinical 
documentation does not support that the Provox system which is already available to the enrollee has failed to 
meet the enrollee's needs and it purports deluxe features for speech enhancement which do not pass the 
reasonableness test. The review has determined that the enrollee does not meet the coverage criteria detailed in 
the LCA. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Ultra Voice Plus System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Ultra Voice Plus System.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the gene panel testing provided on March 30, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test informs treatment decisions for the 
enrollee's condition. The Plan denied your request. The Plan says that the records do not include notes from the 
treating physician. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The Local Coverage Determination, L38435, the Plan used in their decision 
to deny services is not binding in this case. The rule does not have Medicare Part B jurisdiction where the 
services were provided. The Plan has not offered any other rationale for their decision to deny services. 
Therefore, we decided that the Plan has to pay for the gene panel testing provided on March 30, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination (92014) and a dilated retinal eye exam 
(2022F) provided on November 16, 2020. 
 
You asked the Plan to pay for an eye examination (92014) and a dilated retinal eye exam (2022F). You say that 
you were not aware that the Plan was the primary insurance payer for the member until December, after the 
other insurance payer recouped the payment made on the claim. The Plan denied your request. The Plan says 
according to Medicare guidelines an original claim submission must be filed to the appropriate Medicare 
claims processing contractor no later than 12 months, or one calendar year, after the date the services were 
furnished." The Plan also says that the claim was untimely, and the submission did not meet the exception 
criteria guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for an eye examination (92014) and a dilated retinal eye exam (2022F) was not 
filed until December 15, 2021. This means that more than one calendar year from the date of service had 
passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an eye 
examination (92014) and a dilated retinal eye exam (2022F) provided on November 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator 
device. 
 
You asked the Plan to pre-approve an Optimizer Smart Implantable Pulse Generator device. You say that there 
are clinical findings which support the medical necessity of the requested procedure. You say that the requested 
procedure is vital and beneficial treatment for the enrollee. The Plan denied your request. The Plan says 
medical studies have not proven that the requested item is helpful for the treatment of the enrollee's health 
problems. 
 
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 an Optimizer Smart Implantable Pulse 
Generator device. Our reviewer says that an Optimizer Smart Implantable Pulse Generator device is not 
considered medically reasonable and necessary in this case. Our physician reviewer found cardiac contractility 
modulation (CCM) remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Optimizer Smart Implantable Pulse Generator device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse 
Generator device.