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

We decided that the Plan does not have to pre-approve a new continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no proof that the current machine is not functioning.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the current machine is under a manufacturer voluntary recall. The record does not indicate the medical
necessity of this request. The manufacturer is responsible for making arrangements to deliver a new machine. The elements of the coverage determination are mot 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a new continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wound care supplies (A6446, A6456, A6216, A6454).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a wound that qualifies for treatment.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have lymphedema hyperpigmentation of bilateral lower extremities but no notable wound. Wound care supplies were requested. You do not have evidence of a qualifying wound that would justify this request, based on the provided documentation. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve wound care supplies (A6446, A6456, A6216, A6454).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the proton treatment delivery (77523) and the computed tomography guidance for placement of radiation therapy (77014) rendered by the out-of-network (OON) provider on March 31, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the proton treatment delivery (77523) and the computed tomography guidance for placement of radiation therapy (77014) rendered by the out-of-network (OON) provider on March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the panel testing services provided on March 15, 2021.
You asked the Plan to pay for the services provided. You say that the services were required by the ordering
physician to treat the enrollee. The Plan denied your request. The Plan says the testing is 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.
The file shows that a urinary tract infection panel testing was provided. 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 services provided. Our physician reviewer found that the clinical value of the
provided testing in the setting of urinary tract infections remains unproven in the reviewed medical literature. A
urinalysis would be the appropriate test for urinary tract infection. Therefore, the services at issue in this case
were not medically reasonable or necessary to treat the enrollee's condition.
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 services provided have not been met. Therefore, we decided that the Plan
does not have to pay for the panel testing services provided on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular genetic testing provided on
April 29, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says testing for risk
stratification in asymptomatic individuals has not been demonstrated in peer-reviewed literature.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
It appears the testing at issue may have been ordered by an unsolicited outreach telephone call to the enrollee.
The records do not indicate this testing was initiated by the enrollee or the enrollee's treating physician. The test
at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening
purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular genetic
testing provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99215) provided on May 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the outpatient office visit (99215) provided on May 6, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation rendered on February 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 97014 is not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure code 97014 (electrical stimulation therapy) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the electrical stimulation rendered on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone marrow smear interpretation rendered on April 16, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an office setting; however, the file shows that the specimen was obtained in the outpatient hospital setting and should have been billed with POS code 22.
Therefore, we decided that the Plan does not have to pay for the bone marrow smear interpretation rendered on April 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage beyond the Plan's limit for routine
transportation.
You asked the Plan to pre-approve additional mileage for routine transportation. You say that your doctor's
office is further than the Plan's mileage limit. The Plan denied your request. The Plan says routine
transportation is not covered beyond 50 miles.
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 Plan's coverage rules apply in this
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving
distance.
We looked at your request, the records in the case file, and the rules. In this case the requested trip is over 50
miles of driving stance. Based on this information, we decided that the Plan's rules for coverage of routine
transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional
mileage beyond the Plan's limit for routine transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, ankle (73610) provided on June 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the diagnostic service. You say that you have enclosed the supporting documentation for consideration. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the radiologic examination, ankle (73610) provided on June 14, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar/sacral epidural injection for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is not supported without a treatment plan showing that the required limits are not being exceeded.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the provider has recommended bilateral L4 and L5 transforaminal epidural steroid injections. The criteria state that no more than two injections can be given in the area where a nerve root exits (transforaminal) during a single setting. This includes one spinal level on both sides of the spine or two spinal levels on one side of the spine. No more than one injection to the space near the spinal canal can be done per session. The review has determined that the enrollee does not meet the criteria for this requested injection. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar/sacral epidural injection for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services rendered on March 26, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99100 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the special anesthesia services rendered on March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmental pneumatic compression device (E0652, E0667) for the enrollee.
You asked the Plan to pre-approve the device. You say that with a basic pump trial, truncal swelling will likely occur. The Plan denied your request. The Plan says the edema does not extend to the chest, trunk, or abdomen.
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 device. 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 bilateral lower extremity lymphedema that does not extend onto the trunk. The record does not indicate a failure of a four-week trial of a basic pump. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmental pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on May 5, 2021.
You asked the Plan to pay for an intraoral complete series of radiographic images. You say that you want the Plan to cover the service. The Plan denied your request. The Plan says the service at issue 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 Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 28, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head).
Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on December 10, 2020.
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 December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services and electrocardiogram (EKG) interpretation and report rendered on January 23, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 99291 and 99292 are not supported and code 93010 is 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, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. The definition of code 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, there is no documentation of critical care services for the first 30-74 minutes to support code 99291 and each additional 30 minutes to support code 99292. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 93010 (EKG interpretation and report) and 92950 cardiopulmonary resuscitation). Code 93010 is a column II code with a modifier indicator of 1 when billed with column I code 92950. Code 93010 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the critical care services and electrocardiogram (EKG) interpretation and report rendered on January 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2-surface resin based composite on a posterior tooth (D2392) for tooth # 20 provided on June 7, 2021.
You asked the Plan to pay for the dental service. You say that on page 143 of the Evidence of Coverage (EOC), item # 10, states that composite restorations will be covered on premolar facial surfaces. You say that tooth # 20 is considered a premolar tooth and is visible when you talk. You also say that if the EOC states that premolar facial surfaces will be covered, this claim should be accepted. The Plan denied your request. The Plan says 2-surface resin based composite on a posterior tooth is not listed as a covered dental service under the optional supplemental dental coverage for the PPO (preferred provider organization) plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the resin based composite on a posterior tooth is not among those covered under this benefit. Additionally, the section of the Evidence of Coverage that the enrollee cites in their appeal is titled "General limitation for the optional supplemental Dental HMO (health maintenance organization) plan only". The record shows that you are enrolled in the Dental PPO plan. Therefore, we decided that the Plan does not have to pay for the 2-surface resin based composite on a posterior tooth (D2392) for tooth # 20 provided on June 7, 2021.