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

 
We decided that the Plan does not have to pre-approve four (4) hours of neuropsychological testing. 
 
You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says four (4) hours of neuropsychological testing 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve four (4) hours of neuropsychological 
testing. Our reviewer says that four (4) hours of neuropsychological testing not considered medically 
reasonable and necessary in this case. Our physician reviewer found that based on review the records provided, 
this enrollee has had difficulty with memory issues and amnesia. The documentation shows this enrollee had 
testing in September 2020 and desire to retest the enrollee in 1-2 years. Utilizing the criteria from LCD L33632 that this testing is intended to diagnose and characterize the neurocognitive effects of medical disorders that 
impinge directly on or indirectly on the brain including detection of neurologic disease based on quantitative 
assessment of neurocognitive abilities, differential diagnosis between psychogenic and neurogenic syndromes, 
delineation of neurocognitive effects of central nervous system disorders, neurocognitive monitoring of 
recovery or progression of central nervous system disorders or assessment of neurocognitive function for the 
formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders, 
this enrollee does not meet the criteria as the enrollee is not showing severity of symptoms that would warrant 
this type of diagnostic treatment and is therefore not appear medically necessary or reasonable. The 
neuropsychological testing as outlined documentation is unclear the questions needed to be answered by this 
testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of four (4) hours of neuropsychological testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve four (4) hours of neuropsychological testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says medical-necessity rules have not been met for the requested 
item. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested home ventilator is not medically reasonable and necessary in this case. Our physician 
reviewer found that, if you have chronic carbon dioxide (CO2) retention, you may benefit from bi-level 
positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep as an 
outpatient. However, Medicare does not cover a ventilator when used as BiPAP.  
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a denture relign (D5741) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 17, 2022 through 
October 15, 2022. Therefore, we decided that the Plan does not have to pre-approve a denture relign (D5741)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) 
 
You asked the Plan to pre-approve a CGM. You say that you check your blood sugar 4 times a day and you 
take Lantus once a day and Novolog 3 times a day with meals. The Plan denied your request. The Plan says the 
records do not show you administer insulin three times a day or are on a continuous subcutaneous infusion 
pump or that you require frequent insulin dose adjustment based on blood glucose monitoring. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM. Our reviewer says that you do 
not meet criteria for a CGM. Our physician reviewer found you are a 64-year-old female with a past medical history of hypertension, stroke, peripheral neuropathy, depression, chronic constipation, and type I diabetes 
mellitus. You are on fixed dose daily insulin glargine (Lantus) 10 units subcutaneous every night. Your insulin 
regimen and home blood glucose trend are stable. You are not insulin treated with three or more daily 
administrations of insulin or a Medicare-covered continuous subcutaneous insulin infusion pump. Your insulin 
treatment regimen does not require frequent adjustment bon the basis of testing results. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim complete mandibular denture (D5811). 
 
You asked the Plan to pre-approve the interim complete mandibular denture. You say that you feel this denture 
should be covered by the Plan. The Plan denied your request. The Plan says this service is not covered under 
your benefit package. 
 
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 an 
interim complete mandibular denture (D5811).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the infusion services received on March 10, 
2022, and April 16, 2022. 
 
You asked the Plan to waive the copayment for the infusion services. You say that you feel these services were 
billed incorrectly and that you should only pay a $30 copayment. The Plan denied your request. The Plan says 
the claims have been processed correctly per your plan benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for each Medicare-covered surgery or other services at an outpatient hospital or ambulatory surgical 
center, including but not limited to hospital or other facility charges and physician or surgical charges. 
 
 You have been asked to pay a $200 copayment for each the infusion services, for a total of a $400 copayment. 
The infusion services were received in an outpatient hospital facility. The infusion services fall within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the infusion services 
received on March 10, 2022, and April 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cala Trio system (external upper limb tremor 
stimulator of the peripheral nerves of the wrist). 
 
You asked the Plan to pre-approve the Cala Trio stimulator. You say that you believe that there is sufficient 
literature to support the effectiveness of this treatment. The Plan denied your request. The Plan says this is 
experimental and cannot be covered by Medicare. 
 
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 Cala Trio stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is diagnosed with extrapyramidal and movement disorders, Spasmodic 
torticollis, and Essential tremor. There is insufficient evidence in the medical literature to support that the Cala 
Trio device is effective in providing sustained clinical benefit for the enrollee's conditions. 
 
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 Cala Trio stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the Cala Trio system (external upper limb tremor stimulator of the peripheral 
nerves of the wrist).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF is the best level of care for you. The Plan denied 
your request. The Plan says IRF care is not medically necessary and you can be managed at a lower level of 
care. 
 
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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does 
not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require or can tolerate this therapy on an intensive IRF level. You are already ambulating 100 feet with 
minimal assistance with a walker. Therapy documents fatigue is limiting you. Your needs can be met safely at 
a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown restorations for teeth #'s 10 and 11. 
 
You asked the Plan to pre-approve these dental services. You say that these services should be covered by the 
Plan. The Plan denied your request. The Plan says these dental services cannot be covered.  
 
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 these dental 
services. Our reviewer says that the requested dental services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found due to the lack of complete dental records showing 
documentation of the completion of the root canals on teeth #'s 10 and 11, the criteria for coverage for crown 
restorations cannot be determined for teeth #'s 10 and 11. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these dental services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve crown restorations for teeth #'s 10 and 11.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81455) provided on July 1, 2021. 
 
You asked the Plan to pay for laboratory services. You say that you disagree with denial of this claim. The 
requested test was ordered by the treating physician because the test results were needed to help determine the 
course of treatment for the enrollee. The Plan denied your request. The Plan says the claim was billed with a 
date of service inconsistent with Medicare rules governing laboratory services. There is no documentation to 
support genetic testing on the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service for a clinical laboratory test or 
the technical component of physician pathology service must be the date the specimen was collected. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the specimen was collected 
on June 18, 2021, rather than the billed date of service July 1, 2021. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services (81455) provided on July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64635 and 64636 billed for date of service 
February 23, 2022. 
 
You asked the Plan to pay for procedure code 64635 and 64636. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64635 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 64635 have not been met.  
 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 64636 
is an add-on code and has not been billed with an appropriate primary procedure code, since Medicare rules for 
the primary procedure code was found to not be met. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 64635 and 
64636 billed for date of service February 23, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (82542 and 83970) provided on April 19, 2021. 
 
You asked the Plan to pay for codes 82542 and 83970. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for codes 82542 and 83970 by a contract provider. The file does not show that the 
plan provided notice that codes 82542 and 83970 would not be covered. Under Medicare rules, this means 
codes 82542 and 83970 are considered approved by the plan. Therefore, we decided that the Plan has to pay for 
the laboratory services (82542 and 83970) provided on April 19, 2021.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service October 23, 
2021. 
 
You asked the Plan to pay for procedure code 76140. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service October 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy rendered on December 8, 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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is not covered. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The services at issue are infrared therapy. These services are not 
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the infrared therapy 
rendered on December 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided from 
November 25, 2021, to December 24, 2021. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item billed 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. 
 
We find that CPT code E0675 is not supported in the medical record. Specifically, the enrollee used the 
equipment in the facility during and/or after surgery. The documentation shows that the enrollee was inpatient 
for these dates of service. Any payment for services furnished to the enrollee while an inpatient is included in 
payment under the facility claim. Based on this information, we decided that Medicare rules for coverage of the 
pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pay for 
the pneumatic compression device (E0675) provided from November 25, 2021, to December 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services provided on April 29, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network 
care. 
 
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 office visit services provided on April 29, 
2022, by an out-of-network (OON) provider.