Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in-home video electroencephalography (EEG) monitoring to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve in-home video electroencephalography (EEG) monitoring. You say that you feel these services should be covered. The Plan denied your request. The Plan says the requested services can be provided to the enrollee 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 in-home video electroencephalography (EEG) monitoring 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 non-emergency transport.
You asked the Plan to pre-approve the non-emergency transport. You say that you have Parkinson disease and are bed ridden. You say that you need a stretcher to be transported to your doctor's office and you have non-emergent benefits. The Plan denied your request. The Plan says transportation is not covered by your benefit plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we decided that the Plan does not have to pre-approve the non-emergency transport.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical radiofrequency ablation services (64633).
You asked the Plan to pre-approve cervical radiofrequency ablation services. You say that this procedure is medically necessary for the enrollee's pain. The Plan denied your request. The Plan says the criteria for coverage have not been met for the required sites of the requested therapy.
The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency ablation services is subject to the criteria listed 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 cervical radiofrequency ablation
services. Our reviewer says that the requested procedure is not medically necessary and reasonable. Our physician reviewer found the enrollee is an 83-year-old female with chronic neck pain. In this case, there is no documentation the member has undergone any medial branch blocks (MBBs) at the requested anatomical sites. Review of the interventional pain management procedural requests for this member over the last year show many requested and approved interventional pain procedures. There have been no requested MBBs for these anatomical locations. The review has determined that the enrollee does not meet the criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cervical radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical radiofrequency ablation services (64633).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-network provider.
You asked the Plan to pre-approve ophthalmology services with an out-of-network provider. You say that you want to see this provider who performed your surgery in 2008. The Plan denied your request. The Plan says there are in-network providers who can service your 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88305, 88312) provided August 27, 2020.
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says payment for this service is included in the facility payment.
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 codes 88305, & 88312 are not supported in the medical record. Specifically, the codes billed have a professional component / technical component indicator of 1. For this type of bill, payment is processed under the Outpatient Prospective Payment System and separate payment is not issued. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (88305, 88312) provided August 27, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve monitored anesthesia care for the facet joint injection.
You asked the Plan to pre-approve the anesthesia services. You say that the requested anesthesia services are not medically necessary. The Plan denied your request. The Plan says there is no documentation of the need for anesthesia services to successfully perform this procedure in the clinical notes.
The Plan follows Medicare rules. Medicare rules say that neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely considered medically reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the anesthesia services. Our reviewer
says that the criteria for coverage have not been met. Our physician reviewer found there is no rare or unique circumstance that is unequivocal and clearly documented in the medical record which makes sedation medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pre-approve monitored anesthesia care for the facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on
April 22, 2021.
You asked the Plan to pay for the CT. You say that you would like the plan to reconsider their denial. The Plan
denied your request. The Plan says the services billed are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
for the CT has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore,
we decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on
April 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ablation of malignant prostate tissue (transrectal)
with high intensity-focused ultrasound (HIFU) including ultrasound guidance (55880).

You asked the Plan to pre-approve the ablation of malignant prostate tissue (transrectal) with high intensityfocused
ultrasound (HIFU) including ultrasound guidance. You say that the service is medically necessary. The
Plan denied your request. The Plan says HIFU treatment in prostate cancer is considered medically necessary
when the enrollee's PSA is less than 10. The most recent lab value that we received indicates the enrollee's PSA
is 14.

The Plan must follow Medicare rules. Medicare rules say that HIFU is considered medically necessary when all
of the criteria listed in the Medicare Rules section of this letter are met.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the ablation of malignant prostate tissue (transrectal) with high intensity-focused ultrasound
(HIFU) including ultrasound guidance have not been met. Specifically, the enrollee's PSA is not less than 10.
This means the service is not medically necessary. Therefore, we decided that the Plan does not have to preapprove
the ablation of malignant prostate tissue (transrectal) with high intensity-focused ultrasound (HIFU)
including ultrasound guidance (55880).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) and unlisted special service, procedure or report (99199) purchased April 16, 2021.
You asked the Plan to pay for the orthosis. You say that your current brace was over 3 years old and you confirmed with the Plan that you were due for a replacement. Now after your diligence and work to solve this issue and save time and money it is being denied due to efficiency. The Plan denied your request. The Plan says the provider is not certified for Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) and unlisted special service, procedure or report (99199) purchased April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb pneumatic compression device (E0676).
You asked the Plan to pre-approve intermittent limb compression device. You say that this is medically necessary. The Plan denied your request. The Plan says this is used for a preventive service and would be an excluded benefit.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pre-approve an intermittent limb pneumatic compression device (E0676).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 26.
You asked the Plan to pre-approve the dental service. You say that the requested service is medically
necessary. The Plan denied your request. The Plan says root canal 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 requested root canal is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal
(D3310) for tooth # 26
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 care is medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0651) provided April 14, 2021.
You asked the Plan to pay for the orthosis. You say that you have attached all pertinent documentation and feel this claim should be paid. The Plan denied your request. The Plan says there is evidence of misrepresented services.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid physician order, proof of delivery or a delivery ticket to indicate the specific supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0651) provided April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete mandibular denture. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, complete mandibular denture (D5120) is limited to one procedure every five plan years. The record shows that you received a complete mandibular denture (D5120) on December 5, 2018 and your complete mandibular denture (D5120) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on April 9, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you cannot afford to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $95 copayment for diagnostic and nuclear medicine radiological services. You have been asked to pay a $95 copayment for the CT scan. The CT scan falls within the diagnostic and nuclear medicine radiological 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 the computed tomography (CT) scan you had on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional antibody stain procedure (88341) provided on February 9, 2021.
You asked the Plan to pay for an additional antibody stain procedure. You say that this is supported in the records. The Plan denied your request. The Plan says this cannot be paid without an appropriate primary code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88341 is an add on code that must be billed with the primary code, 88342. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an additional antibody stain procedure (88341) provided on February 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the dual-energy x-ray absorptiometry coded 77080 provided on January 29, 2021.
You asked the Plan to pay for the dual-energy x-ray absorptiometry. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 77080 is dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine). We find that CPT code 77080 is not supported in the medical record. Specifically, this code was billed with a primary diagnosis code of Z79.52 (Long term (current) use of steroids). This is an unacceptable primary diagnosis code.
Based on this information, we decided that Medicare rules for coverage of the dual-energy x-ray absorptiometry have not been met. Therefore, we decided that the Plan does not have to pay for the dual-energy x-ray absorptiometry coded 77080 provided on January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) for teeth # 30 and 31.
You asked the Plan to pre-approve the dental services. You say that you need these implants. You say that without them, you cannot get a partial denture either. You also say that you are having other issues with your teeth as a result. The Plan denied your request. The Plan says surgical placement of implant bodies are not listed as covered services.
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 surgical placement of implant bodies are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) for teeth # 30 and 31.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transcatheter permanent occlusion and transcatheter therapy and embolization (61624, 75894).
You asked the Plan to pre-approve the transcatheter permanent occlusion and Transcatheter therapy and embolization. You say that the service is medically necessary The Plan denied your request. The Plan says there are in-network providers that can perform this service.
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 transcatheter permanent occlusion and transcatheter therapy and embolization (61624, 75894).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and laboratory services provided on December 28, 2020 by a non-participating provider.
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 rendered by a non-participating 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 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 and laboratory services provided on December 28, 2020 by a non-participating provider.