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

 We decided that the Plan does not have to pay for a shoulder brace (L3960) provided on August 25, 2021.  You asked the Plan to pay for a shoulder brace. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  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 relevant medical records which support medical necessity for the supplies provided in this case. The provided medical records do not address the item at issue. 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 a shoulder brace (L3960) provided on August 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services provided from July 2, 2021, to July 31, 2021.  You asked the Plan to pay for the medical services. You say that the enrollee was discharged from hospice prior to these services being rendered. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on July 2, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the medical services provided from July 2, 2021, to July 31, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (95886, 95957, 95909) provided on January 28, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.  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 (List separately in addition to code for primary procedure)". The CPT Code Manual definition of code 95957 is "Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis)". The CPT Code Manual definition of code 95909 is "Nerve conduction studies; 5-6 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 the services. Our reviewer says that the use of codes 95886, 95957, and 95909, is not supported by the records provided. Our reviewer found that code 95886 would not be covered as nerve conduction studies were not documented. For code 95957, the procedure report does not include documentation of a computer digital analysis of an EEG per CPT code description. For code 95909, the procedure report does not document nerve conduction studies. The procedure report does document pedicle screw stimulation, but nerve conduction studies would not be reported for this service.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (95886, 95957, 95909) provided on January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on May 5, 2021.  You asked the Plan to pay for the services provided. You say that there is no agreement that the billed codes are included in the dialysis rate. The Plan denied your request. The Plan says the tests are not separately reportable.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable.     We looked at the file and the rules. The records show that the enrollee received ESRD treatment, including lab services. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the preventive procedure (D1999) and bitewing x-rays (D0274) provided on August 5, 2021.  You asked the Plan to pay for the preventive procedure and bitewing x-rays. You say that you would like to appeal the $86.00 charge because you did not know anything about x-rays or vision. The Plan denied your request. The Plan says the preventive procedure is not covered under the Plan. The Plan also says that the bitewing x-rays do not meet the benefit criteria.  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, unspecified preventive procedure (D1999) is not among those covered under this benefit. The contract says that bitewing x-rays (D0274) are not covered in the same year as a full mouth set of x-rays (D0210). The record shows that you received a full mouth set of x-rays (D0210) on April 22, 2021 and you were therefore unable to receive bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999) and bitewing x-rays (D0274) provided on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on February 2, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a ramp, (S5165).
You asked the Plan to pre-approve a ramp. You say that you cannot stand or walk on your own. You are in a wheelchair and cannot exit or enter the home on your own. The Plan denied your request. The Plan says that the records do not support that a ramp is medically necessary, and the enrollee's needs could be met with a less costly alternative.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 ramp. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had been living in an apartment with a broken elevator but had moved to her daughter's home. The daughter's home appears to be a split-level home with the doors raised and only accessible via stairs. In order to safely and independently utilize the doors, a ramp would be needed here. The records suggest this placement is more permanent. Therefore, the ramp will be considered medically 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 ramp have been met. Therefore, we decided that the Plan has to pre-approve a ramp, (S5165).
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 a pneumatic compression device (E0675 and E0673), provided on March 11, 2020.
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673), provided on March 11, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient mental health services provided on March 16, 2021.  You asked the Plan to pay for the services provided. You say that the physician provided services in good faith. The Plan denied your request. The Plan says there is no referring physician listed on the claim.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at the file and the rules. The records do not indicate there was a referral from the enrollee's primary physician for the services at issue. There is no documentation of attempts made to consult the primary physician. 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 outpatient mental health services provided on March 16, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).  You asked the Plan to pre-approve the diagnostic service. You say that you are appealing the denial of a PET scan. This is for the treatment plan for your Cancer. The Plan denied your request. The Plan says that the submitted documentation does not support medical necessity.  The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.   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 diagnostic service. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found in this case the record indicates that the enrollee has undergone an excision of melanoma in 2020 and is undergoing active surveillance. The record does not indicate that the enrollee has had three post treatment scans.  The elements of the coverage rule are satisfied.  The requested service is recommended.  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 diagnostic service have not been met. Therefore, we decided that the Plan has to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve epidural steroid injections (CPT code(s): 64484 x 3, and 64483 x 3), for the enrollee.  You asked the Plan to pre-approve the injections. You say that the services are necessary. The Plan denied your request. The Plan says the records submitted noted that the enrollee receives adequate pain relief (46-65%) from current pain medications, and the pain is stable. The Plan states the records do not provide imaging results for lumbar spine and does not provide conservative treatments tried/failed (other pain 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 the injections. Our physician reviewer found no imaging is documented. The physical exam does NOT record radiculopathy. There is no documentation of conservative therapies recently tried. The request does not meet the criteria of the LCD or NCD. The request is 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injections (CPT code(s): 64484 x 3, and 64483 x 3), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the duplex scan services coded 93880 provided on August 12, 2021.  You asked the Plan to pay for the duplex scan services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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 93880 is a column II code to column I code 76536. 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 the duplex scan services coded 93880 provided on August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on March 3, 2021.  You asked the Plan to pay for the services provided. You say that there is no agreement that the billed codes are included in the dialysis rate. The Plan denied your request. The Plan says the tests are not separately reportable.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable.   We looked at the file and the rules. The records show the enrollee received lab testing as part of treatment for ESRD. Labs should bill the facility directly for lab services as they are considered part of the composite rate.  No other payment for these services is allowed. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on May 4, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  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 76857 is a column II code to column I code 76775. 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 ultrasound services provided to the enrollee on May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve gradient compression stockings, below the knee 30-40 mmhg.  You asked the Plan to pre-approve the stockings. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no wound assessment.  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 stockings. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has chronic venous insufficiency dermatitis but no ulcerations. The elements of the coverage criteria are not satisfied.  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 stockings have not been met. Therefore, we decided that the Plan does not have to pre-approve gradient compression stockings, below the knee 30-40 mmhg.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 4) provided on September 25, 2021.
You asked the Plan to pay for the dental services. You say that you called the plan to see what is covered. You say that nothing was mentioned about this x-ray. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the frequency limit has been exceeded. The record shows that the Plan paid for the initial periapical x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the additional periapical x-rays (D0230 x 4) provided on September 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) additional physical therapy (PT) visits.
You asked the Plan to pre-approve five (5) additional PT visits. The Plan denied your request. The Plan says the clinical documentation provided and reviewed shows that the member has a diagnosis of pelvic and perineal pain. The information provided does not compare current level of function to prior level of function and the notes do not verify progressive functional improvement. There has been adequate time since the start of care to instruct and transition the member to a home program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 five (5) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the records submitted, subsequent visits did not show any improvement. The enrollee was given a home exercise program (HEP) and he was noted to be non-compliant with the HEP. According to the note dated November 23, 2021, the enrollee reported little benefit from PT and would like to a pursue benign prostatic hyperplasia procedure. On review of the limited available records, the enrollee does not meet Medicare coverage criteria for the requested therapy visits. The documentation does not support coverage for the requested therapy visits. Based on the records provided, the requested therapy is not generally accepted as specific and effective for the enrollee. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of five (5) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve five (5) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumbar/Sacral Facet Joint Radiofrequency.
You asked the Plan to pre-approve Lumbar/Sacral Facet Joint Radiofrequency. You say that you would like
reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan
says the documentation submitted does not include notes from the provider that say the member's pain was
reduced by at least 80% after 2 injections on different days.
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 Lumbar/Sacral Facet Joint
Radiofrequency. Our reviewer says that the requested items/services are not considered medically reasonable
and necessary in this case. Our physician reviewer found the LCD requires 2 separate sets of Medial Branch
Blocks that produce 80% pain relief. Only one set of blocks was performed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Lumbar/Sacral Facet Joint Radiofrequency have not been met. Therefore, we
decided that the Plan does not have to pre-approve Lumbar/Sacral Facet Joint Radiofrequency