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

We decided that the Plan does not have to pay for the services (95955, 95861, 95937, 95908, 95927) provided on March 18, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of codes 95955, 95861, 95937, 95908, and 95927, is not supported by the records provided. Our reviewer found that per the technical report, "EEG was symmetric throughout the procedure. No lateralizing events were observed during this case". CPT 95955 is an inappropriate code to report for baseline EEG, as there is a more appropriate code
to report, additional testing would be inclusive to the intraoperative monitoring code. For CPT 95861, the technical report does not include enough detail to confirm muscles testing at rest and during contraction has been performed. For CPT 95937, the technical report does not include documentation of neuromuscular junction testing. For CPT 95908, the technical report does not include documentation of nerve conduction studies which include latency, amplitude and conduction velocity. Therefore, this procedure cannot be verified. For CPT 95927, the technical report does not include documentation to support stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; trunk or head. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (95955, 95861, 95937, 95908, 95927) provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive audiometry evaluation provided on
May 20, 2021.
You asked the Plan to pay for a comprehensive audiometry evaluation. The Plan denied your request. The Plan says you must use a doctor in our hearing network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a comprehensive audiometry evaluation provided on
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the criteria is not met.
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 the monitor. Our reviewer says that the
requested monitor is not medically reasonable or necessary. Our physician reviewer found the record does not
indicate that the enrollee uses insulin more than three times a day or adjust the dose frequently. The elements of
the coverage criteria are not satisfied.
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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on July 18, 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 procedure code 99053 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Billed procedure code 99053 (service(s) provided between 10:00 PM
and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate
Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox solution 100 units 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 being used for a non-medically-accepted or off-label reason.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is insufficient support made for using Botox for writer's cramp based on current high quality studies. There is no Food and Drug Administration (FDA) approval for this medication to be used for this indication. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox solution 100 units for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (28003) provided on April 30, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 28003 is "Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas". We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 28003 is supported by the records provided. Our reviewer found that the operative report documents two procedures performed with different incisions. No documentation was noted that more than one incision and drainage was performed or billed. Modifier -59 would be appropriate as two separate procedures were 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 services have been met. Therefore, we decided that the Plan has to pay for the services (28003) provided on April 30, 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the application of short arm splint (29125)
in the emergency room rendered on May 16, 2021.

You asked the Plan to waive the copayment for the application of short arm splint in the emergency room. You
say that you were in the emergency room the day prior and was stitched unsuccessfully for the injury and then
discharged. You also say you were told to go back to the emergency room by their staff the next day, for a
splint to immobilize the injured area. You also say you were told that there would be no second charge as it
was linked to the visit on May 15, 2021. The Plan denied your request. The Plan says you were charged the
correct copayment 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 $90
copayment for each emergency room visit.

You have been asked to pay a $90 copayment for the application of short arm splint in the emergency room.
The application of short arm splint in the emergency room falls into the Emergency Care 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 application of short arm splint (29125) in the emergency
room rendered on May 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on April 14, 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. The rules say that the CxBladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on June 9, 2021.
You asked the Plan to pay for the dental service. You say that you were advised before the pandemic that you need a lot of dental work done. You say that you did not agree. You say that you went to a new dentist. You also say that you feel that you saved the plan a lot of money by not getting all of those other services done. The Plan denied your request. The Plan says 1 complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.
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 an complete series x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a complete series x-ray that you received on February 28, 2019. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on June 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluorescence in situ hybridization (FISH) testing provided on June 7, 2021.
You asked the Plan to pay for the FISH testing. The Plan denied your request. The Plan says this is not a covered screening service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The FISH testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the fluorescence in situ hybridization (FISH) testing provided on June 7, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the request does not show skilled nursing or therapy needs.
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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you have stabilized medically, and are ready to discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You do not have any further exacerbations of chronic medical problems. Your physical function is at or near the baseline, and you can receive further services 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Soliqua for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Soliqua for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve moderate sedation for facet joint injections.
You asked the Plan to pre-approve moderate sedation. You say that you were told that the needles are very uncomfortable and painful, and this sedation was recommended. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not clearly show why this is needed.
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 moderate sedation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found medical literature states that use of analgesic sedation for diagnostic medial branch nerve blocks could contribute to decreased pain after the procedure, confounding the diagnostic value and potentially increasing the rate of subsequent unnecessary denervation procedures. There is no specific clinical rationale for this sedation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of moderate sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve moderate sedation for facet joint injections
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) provided on April 29, 2021.
You asked the Plan to pay for the dental service. You say that the crowns were pre-approved under this dentist initially. You say that your coverage changed in April without your consent. You say that you did not know that you no longer had coverage. You also say that you would not have gone forward with the crown had you known. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental service received out of network are not covered. The Plan also says you were advised of the change in coverage prior to the date of 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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain crown (D2740) provided on April 29, 2021.
Your complaint about your change in coverage is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309, 99310) rendered by the out-of-network (OON) provider on February 3, 2021 and February 17, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309, 99310) rendered by the out-of-network (OON) provider on February 3, 2021 and February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee appears to be improving but is still not stable enough for transfer and
should only require short-term additional acute care services that can safely be completed at the current facility.
There are no services at the LTACH that the enrollee requires that are not already available and covered at the
current facility. Transfer to a lower level of care may be considered when treatment has completed and the
enrollee is more stable.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Aminolevulinic acid hcl for topical administration (J7308) rendered on June 28, 2021.
You asked the Plan to waive the copayment for Aminolevulinic acid hcl for topical administration. You say that you received an approval letter for the service, and it does not indicate that you have a copayment or coinsurance. You also stated you assumed the Plan would pay 100% since it was approved. You also state the provider did not tell you had to pay anything other than the office visit. The Plan denied your request. The Plan says you were charged the correct cost sharing 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 20% coinsurance for Medicare Part B prescription drugs.
You have been asked to pay $78.60 coinsurance, which is 20% of the allowed amount for Aminolevulinic acid hcl for topical administration ($393 allowed amount x 20% coinsurance = $78.60). Aminolevulinic acid hcl for topical administration falls within the Medicare Part B Prescription Drugs benefit category. The record shows that the service is covered with a 20% coinsurance payment. 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 Aminolevulinic acid hcl for topical administration (J7308) rendered on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 fillings provided on July 20, 2021.

You asked the Plan to pay for the dental services. You say that you did not realize that your policy only covered 2 cavities. You say that your dentist advised that you needed 4 cavities. You also say that you are currently dealing with hardship at your current age and your income benefits are very low. The Plan denied your request. The Plan says 2 fillings are covered per calendar year. The Plan also says that the frequency limit has been exceeded.

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 frequency limit has been exceeded. The record shows that the Plan paid for 2 filling you received on July 15, 2021. Therefore, we decided that the Plan does not have to pay for the 2 fillings provided on July 20, 2021.