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

We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve 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 replacement durable medical equipment is covered in cases of irreparable wear or when it has exceeded the reasonable lifetime period of five years. We looked at the file and Medicare rules. The file shows that the current CPAP is not irreparably damaged or more than five years old. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
You asked the Plan to preapprove the CGM. You say that the CGM should be covered. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria for a CGM.
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, or 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 the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650, L8680). 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that the enrollee is unable to function. The 
Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for 
patients who have undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to 
implantation. Such screening must include a psychological evaluation.  
 
The file does not show that a psychological evaluation has been conducted in conjunction with this request for 
a spinal cord stimulator trial. Therefore, we decided that the Plan does not have to pre-approve a spinal cord 
stimulator (63650, L8680).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) (95957) 
nerve conduction studies (95908) and needle electromyography (95886) provided October 2, 2020. 
 
 
You asked the Plan to pay for the intraoperative monitoring services. You say that based on the CPT 
guidelines, CPT codes 95957, 95908, and 95886 are valid procedure codes for the intraoperative monitoring 
services billed. The Plan denied your request. The Plan says these services are not supported by the medical 
records. 
 
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 codes 95957 is digital analysis of electroencephalogram (EEG) 
(e.g., for epileptic spike analysis), 95908 is nerve conduction studies; for 3-4 studies and 95886 is needle 
electromyography, per each extremity with related paraspinal areas when performed, done with nerve 
conduction, amplitude and latency/velocity study; for five or more muscles studied, innervated by three or 
more nerves or four or more spinal levels (listed separately in addition to code for primary procedure). 
 
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 intraoperative monitoring services. Our reviewer says 
that the medical records do not support that the criteria for the billed services. Our reviewer found the 
documentation submitted was reviewed and does not meet the criteria. For CPT 95957, the technical report 
does not document placement of sensors on the enrollee's head to monitor and record the brains electrical 
activity. CPT 95957 would not be reported for real time monitoring. For CPT 95908, the technical report 
documents "pedicle screw stimulation." This is the incorrect code to report for nerve conduction studies, which 
assess amplitude, latency, and nerve conduction velocities. For CPT 95886, this procedure would not be 
covered, as it includes nerve conduction studies. Nerve conduction studies cannot be confirmed as performed. 
 
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 intraoperative monitoring services have not been met. Therefore, we 
decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) (95957) nerve 
conduction studies (95908) and needle electromyography (95886) provided October 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued stay at a skilled nursing facility (SNF). 
 
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 are no skilled nursing needs identified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested continuation of services is not medically reasonable or necessary. Our physician reviewer found there 
are no identifiable skilled nursing or skilled therapy service needs. You do  not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continued stay at a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. 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 pre-approve foot orthotics
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam (92014) provided on June 8, 2021.
You asked the Plan to pay for the eye exam. You say that this was a routine eye exam which should be covered
in full. The Plan denied your request. The Plan says you had a previous routine eye exam which was covered
by the Plan less than two full years ago. This service is only covered once every two years.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers one routine eye exam every two years. This benefit is administered on a rolling
calendar year since your last date of service.
We looked at the file and the Plan's rules. Documentation shows that you received a previous routine eye exam
in September 2019, which was paid for by the Plan less than two years before the date in question. Based on
this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore,
we decided that the Plan does not have to pay for the routine eye exam (92014) provided on June 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. You say that the requested treatment is considered safe and effective, as supported by its clinical benefits, continued medical professional adoption, and strong clinical evidence with numerous peer-reviewed studies. The Plan denied your request. The Plan says medical studies have not proven that the requested device is helpful for treatment of the enrollee's health problem.
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 a Vertiflex Superion Interspinous device. Our reviewer says that a Vertiflex Superion Interspinous device is not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is still considered experimental and investigational as its role in the management of spinal stenosis is still uncertain. Therefore, the request is considered 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 a Vertiflex Superion Interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.

You asked the Plan to pre-approve chiropractic services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation is lacking clinical support for additional care.

The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 

We looked at the file and Medicare rules. Review of the file shows that the documentation did not include clinical support for additional care. The enrollee has already received chiropractic services for the last 14 months. The records must show that clinical benefit is expected from ongoing chiropractic care. The documentation does not support this. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemtesa tablet 75mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa tablet 75mg for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD).
You asked the Plan to pre-approve an EGD. You say that an EGD is medically necessary. The Plan denied your request. The Plan says an EGD is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Endoscopy procedures can only be allowed if abnormal signs or symptoms or known disease are present. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an EGD. Our reviewer says that an
EGD is not medically necessary. Our physician reviewer found that the enrollee has a history of GERD with
esophageal stricture managed by scheduled dilations, and of diet-responsive loose stool with an underlying
history of irritable bowel syndrome. Objective evaluation has ruled out celiac disease and infectious causality.
The enrollee's scenario does not meet medically necessary LCD L35350, nor EGD-1 criteria as provided per
eviCore's evidence-based standard-of-care guidance.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of EGD have not been met. Therefore, we decided that the Plan does not have to
pre-approve an EGD
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electro-acupuncture device (P-Stim) (64555 and
L8679).
You asked the Plan to pre-approve a P-Stim. You say that the item is medically necessary. The Plan denied
your request. The Plan says the requested item is considered a form of acupuncture.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, [ADJUDICATOR ENTER CASE SPECIFICS].
Therefore, we decided that the Plan does not have to pre-approve electro-acupuncture device (P-Stim) (64555
and L8679).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care and services provided for diagnoses of malnutrition and mechanically altered diet on March 1 to March 24, 2020.
You asked the Plan to pay for SNF care and services. You say that the SNF care and services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says the clinical documentation does not support the billing of malnutrition or mechanically altered diet.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 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 SNF care and services. Our reviewer says that the requested
SNF care is not medically reasonable and necessary in this case. Our reviewer found that, while this enrollee
had low albumin levels, there is no evidence that the enrollee was not consuming food, not digesting/absorbing
food/nutrients or not consuming a sufficient amount of calories. Therefore, a diagnosis of malnutrition is not
supported.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care and services have not been met. Therefore, we decided that the Plan
does not have to pay for SNF care and services provided for diagnoses of malnutrition and mechanically altered
diet on March 1 to March 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the large bowel.
You asked the Plan to pre-approve a CT of the large bowel. You say that the records provided support that the
requested CT scan is medically necessary. The Plan denied your request. The Plan says a medical need for the
requested service could not be confirmed. The Plan says that the notes do not show that a fecal occult blood test
(FOBT) was performed.
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT of the large bowel. Our reviewer
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee's history of
colonic Crohn's disease heightens his risk for colon cancer, and as such he cannot be considered average risk
for colon cancer or colonic dysplasia. CT colonography may detect synchronous polyps and/or colonic wall
thickening in the enrollee but will not afford opportunity for needed respective polyp removal and histologic
dysplasia surveillance. CT colonography is neither medically appropriate for the enrollee, nor given his
provided records can he be expected to reliably and timely follow-up by colonoscopy as may be warranted by
colonography results. Another attempt at optical colonoscopy is medically necessary for the enrollee at this
juncture and not CT colonography.
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 CT of the large bowel have not been met. Therefore, we decided that the Plan
does not have to pre-approve computed tomography (CT) of the large bowel.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided
on July 8, 2021.
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you went for
laboratory services and now owe a facility copayment. The Plan denied your request. The Plan says the claims
were processed correctly, and you are being charged the correct amount.
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 $300
copayment for outpatient hospital facility visits.
You have been asked to pay the allowed amount of $112.88, which is less than the $300 copayment for an
outpatient hospital facility visit. An outpatient hospital facility visit falls within the outpatient hospital services
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 an outpatient hospital facility
visit provided on July 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin injections provided on May 11, 2021.

You asked the Plan to pay for the vitamin injections. You say that this is not a duplicate and medical records are attached. The Plan denied your request. The Plan says the original decision to deny payment is correct.

The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. Medicare rules say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vitamin injections have not been met. Specifically, we find that the physical therapy services at issue in this case were rendered by an NP who is not licensed to provide physical therapy. Also, the drug code reported on this claim refers to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drug is not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the vitamin injections provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6752, D6242).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D6752, D6242).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (99204) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that this care is medically necessary. The Plan 
denied your request. The Plan says they have in-network providers available to handle the enrollee's medical 
needs. 
 
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 
the office visit (99204) to be provided by an out-of-network (OON) provider.