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

 We decided that the Plan does not have to pay for neurology services (procedure codes 51785, 95861, 95870, 95937, 95955) provided to the enrollee on June 23, 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 denied codes remain not supported.  

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 the denied codes is:  

CPT 51785: 

Needle electromyography studies (EMG) of anal or urethral sphincter, any technique  

CPT 95861:  

Needle electromyography; 2 extremities with or without related paraspinal areas  

CPT 95870:  

Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters  

CPT 95937:  

Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method  

CPT 95955:  

Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery)  

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 services at issue in this case were not supported by the medical records. Our reviewer found the technical report in the records does not describes the procedures noted in CPT 51785, CPT 95961, CPT 95870, and CPT 95937. Therefore, these codes cannot be verified. In terms of CPT 95955, this procedure is considered a "special testing" procedure. Additional EEG testing is included in the interoperative monitoring procedure, and should not be reported separately.   

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 neurology services (procedure codes 51785, 95861, 95870, 95937, 95955) provided to the enrollee on June 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation trips.  You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says your benefit only allows up to 60 one-way trips per year.  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.    We looked at your request, the records in the case file, and the rules. The file shows that the Plan covers up to 60 one-way trips per calendar year. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for special anesthesia service (99100) provided on July 21, 2021.  You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 99100 is always bundled for payment and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that code 99100 is always bundled for payment and is not separately payable.   
 We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia service (99100) provided on July 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eight (8) additional PT visits.  You asked the Plan to pre-approve eight (8) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.  
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 eight (8) 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 based on the medical records provided there is no documentation that the additional therapy is generally accepted as specific and effective therapy for the enrollee's condition. The records indicate the enrollee is ambulating without an assistive device and has had no recent falls. Based on records available to this reviewer, 2-12 physical therapy sessions were requested by the enrollee's physician ("1-3 times per week for 2-4 weeks"); the health Plan approved eight visits. The records do not document any acute or unstable medical conditions or changes in function which would necessitate any further skilled therapy visits beyond what have already been approved. Utilization of the home exercise program appears appropriate after completion of the approved eight visits. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is 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 eight (8) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group three power wheelchair with multiple power options.  You asked the Plan to pre-approve a group three power wheelchair with multiple power options. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items.  The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:  1. A neurological condition;  2. Myopathy; or  3. Congenital skeletal deformity.  The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group three power wheelchair with multiple power options.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation trips.  You asked the Plan to provide coverage for additional routine transportation trips. You say that The Plan denied your request. The Plan says benefit only allows 60 one-way trips, combined in and out-of-network, are covered per calendar year.  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.   We looked at your request, the records in the case file, and the rules. The file show that the Plan covers up to 60 one-way trips per calendar year. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve dialysis services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by 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 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 dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional routine transportation trips.  You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says you have exceeded the number of routine transportation trips.  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 a maximum of 30 one-way trips per year to or from plan-approved locations, such as network physicians, medical facilities and pharmacies.  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 provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the immediate upper denture (D5130) provided on April 20, 2021.  You asked the Plan to pay for the dental item. You say that you have had repeated infections on both sides of your upper mouth. You say that a complete denture was the way to go. The Plan denied your request. The Plan says the immediate upper denture is not listed as a covered service.  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 immediate upper denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the immediate upper denture (D5130) provided on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the screening FISH testing (CPT code 88120) provided to the enrollee on March 24, 2021.  You asked the Plan to pay for the screening FISH testing. You say that the claim should be paid. The Plan denied your request. The Plan says cystoscopy in conjunction with bladder tumor markers is standard practice to evaluate patients with symptoms suggesting bladder cancer and to monitor treated patients for recurrence or progression. The Plan states bladder cancer tumor markers performed by any technology immunoassay, molecular or FISH testing, are not covered for screening of all patients with hematuria. The Plan states bladder tumor markers are not expected to be performed until other diagnostic studies fail to identify the etiology of the hematuria. Urine cytology is not considered a bladder tumor marker.  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.  The services are not authorized because screening FISH testing is not a Medicare benefit for the diagnosis listed on the claim N39.3-Stress incontinence (female) (male) and is done for screening purposes. Therefore, we decided that the Plan does not have to pay for the screening FISH testing (CPT code 88120) provided to the enrollee on March 24, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve psychiatric evaluation and psychotherapy to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve psychiatric evaluation and psychotherapy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services can be provided by 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 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 psychiatric evaluation and psychotherapy to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office consultation to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve office consultation. You say that your physician felt that this provider would be better to perform surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated within the Plan 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 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 an office consultation 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 the oral hygiene instructions (D1330), drugs or medicaments (D9630), application of desensitizing medicament (D9910) and application of desensitizing resin (D9911).  You asked the Plan to pre-approve the oral hygiene instructions (D1330), drugs or medicaments (D9630), application of desensitizing medicament (D9910) and application of desensitizing resin (D9911). The Plan denied your request. The Plan says the services are not covered benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the oral hygiene instructions (D1330), drugs or medicaments (D9630), application of desensitizing medicament (D9910) and application of desensitizing resin (D9911).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit.  You asked the Plan to pre-approve a Freestyle Libre 2 sensor kit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.   We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a home ventilator. 
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided by 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 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 a home ventilator to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve routine laboratory services to be provided by an out-of-network (OON) provider.  
You asked the Plan to pre-approve routine laboratory services. You say that you will be out of the state until May 1, 2022. The Plan denied your request. The Plan says the services can be provided by 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 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 routine laboratory services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve non-emergency transportation (A0100).  You asked the Plan to pre-approve non-emergency transportation. You say that you do not have access to transportation, and you need transportation from your home to every medical appointment. The Plan denied your request. The Plan says you have requested non-emergency transportation services to your medical appointments, and you are not going from a hospital to a SNF.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   We looked at the file and Medicare rules. The EOC confirms that the Plan covers non-emergency transportation from a hospital to a SNF. Specifically, you are requesting transportation services from your home to your medical appointments and that is not a covered service with your Plan. Based on this information, we decided that Medicare rules for coverage of non-emergency transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on June 10, 2021.  You asked the Plan to pay for eyeglasses. 
The Plan denied your request. The Plan says supplemental eyewear must be obtained from a provider in the Plan's vision vendor network.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtained from a provider in the Plan's vision vendor network.   
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not obtained from a provider in the Plan's vision vendor network. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a seat lift mechanism.  You asked the Plan to pre-approve a seat lift mechanism. You say that this is medically necessary. The Plan denied your request. The Plan says that the information that they received from your doctor did not tell them that you are unable to walk independently once standing.  The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.  We looked at the file and Medicare rules. The file indicates you are not able to walk once standing. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a consultation to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a consultation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by 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 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 a consultation to be provided by an out-of-network (OON) provider.