Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electric stimulation therapy provided on September 29,
2020.
You asked the Plan to pay for the electric stimulation therapy. You say that the claim processed out-ofnetwork,
but you do not need authorization. You say that the claim should be processed at the in-network level.
The Plan denied your request. The Plan says the code is not valid for Medicare billing purposes.
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 97014 is application of a modality to 1 or more areas;
electrical stimulation (unattended).
We find that CPT code 97014 is not supported in the medical record. Specifically, per the Physician Fee
Schedule, CPT code 97014 has a status indicator of I. This means that CPT code 97014 is not valid for
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the electric
stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for the electric
stimulation therapy provided on September 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not tried and failed zoledronic acid or have a history of an osteoporosis-related fracture.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our physician reviewer found that the enrollee has osteoporosis. The Plan requires a trial of Zoledronic Acid, or a history of osteoporosis-related fracture before they will approve the requested drug. In this case, the enrollee has not met the Plan's requirements for the requested drug. There is no documentation provided indicating that the plan's required drug would likely be less effective or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam, fundus photography and eyeglasses provided on June 8, 2021.
You asked the Plan to pay for the eye exam, fundus photography and eyeglasses. You say that you were not informed of your 2-year benefit and you would have waited to get reimbursed if you were informed. You say that the claim should be paid at the benefit level. The Plan denied your request. The Plan says your maximum benefit has been exceeded.
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 an eye exam and eyewear every two years. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eye exam, fundus photography and eyeglasses have not been met. Specifically, an eye exam and contacts were provided on August 7, 2019, which exhausted your benefits. Therefore, we decided that the Plan does not have to pay for the eye exam, fundus photography and eyeglasses provided on June 8, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
You asked the Plan to pre-approve the RFA services. You say that you have a hard time moving, sleeping, bending, and carrying things. You say that you do not want to be drugged and would like to fix the problem. The Plan denied your request. The Plan says the guidelines for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint nerves are covered when 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 RFA services. Our reviewer says that the records do not show that the RFA services are medically necessary in this case. Our physician reviewer found the records do not show that the enrollee had at least two medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary pain. A single MBB was performed on October 15, 2021 and provided 0% relief. No second confirmatory diagnostic MBBs were documented. 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 RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic pulpotomy (D3220) provided on May 25, 2021.
You asked the Plan to pay for the dental service. You say that this service was medically necessary. The Plan denied your request. The Plan says the therapeutic pulpotomy 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 therapeutic pulpotomy not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the therapeutic pulpotomy (D3220) provided on May 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on June 13, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you were advised by the paramedics that the 
enrollee should not go to the hospital. You also say that you cannot afford to pay this bill. The Plan denied your 
request. The Plan says because the Medicare ambulance benefit is a transport benefit, if no transport is 
provided, then there is no Medicare covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 13, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Additionally, the record shows that you signed a release form refusing transport for the enrollee to a hospital. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on June 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical excision of excess skin of the abdomen. 
 
You asked the Plan to pre-approve surgical excision of excess skin of the abdomen. You say that the services 
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Palmetto GBA considers panniculectomy medically 
necessary when the panniculus hangs below the level of the pubis, and the medical records document that the 
panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, 
infection or chafing) that consistently recurs over 3 months while receiving appropriate medical therapy, or 
remains refractory to appropriate medical therapy over a period of 3 months. 
 
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 surgical excision of excess skin of the 
abdomen. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
record describes a small panniculus. but does not indicate that the panniculus hangs below the level of the pubis 
or that interigo is a chronic problem refractory to treatment. The elements of the coverage criteria are not 
satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical excision of excess skin of the abdomen have not been met. Therefore, 
we decided that the Plan does not have to pre-approve surgical excision of excess skin of the abdomen.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) provided on 
May 11, 2021 to June 22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that the services provided have been very 
beneficial in addressing the back pain you have suffered due to deterioration of the lumbar spine. The Plan 
denied your request. The Plan says enrollee's must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) 
provided on May 11, 2021 to June 22, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265). 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266, 
E0296, and E0297) is not covered; the height adjustment feature is a convenience feature.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a total electric hospital bed (E0265).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88189, 88377) provided on May 21, 2021.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says the records do not include a physician order.
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The submitted medical records do not include a physician order for the laboratory services at issue. 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 (88189, 88377) provided on May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee scope services (29874 and 29881).
You asked the Plan to pre-approve the knee scope services. You say that you would like reconsideration because this procedure is necessary as you would like to avoid surgery. The Plan denied your request. The Plan says the requested procedure 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 the knee scope services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have too much degenerative joint disease in the knee for a knee scope to be effective. 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 knee scope services have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee scope services (29874 and 29881).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 11, 2021, to May 18, 2021.
You asked the Plan to pay for the SNF care provided from May 11, 2021, to May 18, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the services provided were custodial in nature. The Plan also says that custodial care is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care provided from May 11, 2021, to May 18, 2021, have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 11, 2021, to May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers must report services correctly. Procedures should be reported with the Current 
Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the 
Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.We decided that the Plan does not have to pay for the laboratory testing coded 81240 and 81241 provided on 
June 18, 2021. 
 
You asked the Plan to pay for the laboratory testing. 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 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 codes 81240 and 81241 are not supported in the medical record. Specifically, the 
documentation shows that the enrollee had molecular pathology testing. When a laboratory assays two or more 
genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel 
constitutes a single procedural service, so one code must be submitted for the panel. In this case one code was 
not submitted for the panel provided. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory testing coded 81240 and 81241 provided on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable home ventilator. 
 
You asked the Plan to pre-approve a portable home ventilator. You say that , with the enrollee's need for 
continuous oxygen, he meets Medicare's guidelines for non-invasive ventilator due to hypoxia. You say that the 
enrollee has been on continuous positive airway pressure (CPAP) therapy, and this has not been sufficient or 
appropriate for her ventilator requirements. The Plan denied your request. The Plan says a home mechanical 
ventilator with settings could be delivered with Bi-level positive airway pressure (BiPAP) with Average 
Volume-Assured Pressure Support (AVAPS) for this enrollee. 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 portable home ventilator. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the Life2000 
system is not medically necessary. This enrollee has idiopathic pulmonary fibrosis with hypoxic respiratory 
failure. There is no diagnosis of neuromuscular disease or thoracic restrictive disease.  Pulmonary function 
testing does not support a diagnosis of chronic obstructive pulmonary disease (COPD.) There is no 
documentation of carbon dioxide (CO2) retention. This means that the criteria for either a ventilator or BiPAP 
are not met. In addition, the Life2000 system is not a true ventilator, and there is insufficient evidence that it is 
beneficial in the treatment of lung disease. 
 
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 portable home ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a portable home ventilator.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment (A0998) provided on 
June 16, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that the service was denied because the 
ambulance service was out of area. You also say that this was not the case. The Plan denied your request. The 
Plan says there was no transport provided. The Plan also says that if no transport is provided, there is not a 
coverable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 16, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment (A0998) 
provided on June 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance oxygen supplies (A0422) provided on April
27, 2021.
You asked the Plan to pay for the ambulance oxygen supplies. You say that you would like reconsideration
because the member required and ambulance due to needing six liters of supplemental oxygen. The Plan denied
your request. The Plan says the billed supplies are considered incidental to the member's total episode of care.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The
rules also say that payment for items and services is included in the fee schedule payment.
In this case, the CPT Code Manual definition of code A0422 is ambulance (als or bls) oxygen and oxygen
supplies, life sustaining situation
We find that CPT code A0422 is not supported in the record. Specifically, payment for the oxygen is included
in the base payment for the ambulance services. Based on this information, we decided that Medicare rules for
coverage of the ambulance oxygen supplies have not been met. Therefore, we decided that the Plan does not
have to pay for the ambulance oxygen supplies (A0422) provided on April 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee has failed months of conservation treatment. The Plan denied your request. The Plan says that the indication for coverage is not met.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.