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

We decided that the Plan does not have to pay for the chiropractic services provided on April 26, 2021.
You asked the Plan to pay for the office visit (99203), cervical spine x-ray (72040), lumbar spine x-ray (72100), and electrical stimulation therapy (97014). You say that at no time has anyone told you that these services were not covered, and you cannot afford the charges. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic paravertebral facet joint injections for the enrollee.
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 is a lack of evidence that the enrollee's pain improved after the two diagnostic facet joint blocks, with each one providing a consistent minimum of 80% relief.
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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found evidence-based reviews of intra-articular steroid injection of facet joints do not support the
efficacy of repeat injections. Rather, the evidence supports two sets of diagnostic medial branch blocks, and
then radiofrequency ablation if the 80% pain relief threshold is achieved.
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 therapeutic paravertebral facet joint injections for the enrollee.
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 the criteria is met as the enrollee is managing his diabetes with one daily dose of basal insulin. The Plan denied your request. The Plan says the enrollee is not using insulin three or more times per day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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 use insulin with at least three daily injections. The case file directly references the fact that the enrollee only uses insulin once per day.. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay at least half for the scaling and root planing (D4341 x 3), and gingival irrigation (D4921 x 2) provided on February 2, 2021.
You asked the Plan to pay at least half for the dental services. You say that the coverage that you are paying for is double. You say that everything should be covered. You say that you are on a fixed income. You also say that you would like at least half of each bill covered. The Plan denied your request. The Plan says scaling and root planing are not listed as covered services. The Plan says gingival irrigation are not listed as covered services either. The Plan also says that you did not contact them prior to the date of service to verify benefits and provider eligibility.
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 pay at least half for the scaling and root planing (D4341 x 3), and gingival irrigation (D4921 x 2) provided on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on March 20, 2021.
You asked the Plan to pay for the provided item. You say that your old machine broke, and you needed a new one. The Plan denied your request. The Plan says Medicare only covers durable medical equipment from suppliers enrolled in Medicare.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that that you receive your care from a provider who is eligible to provide services under Original Medicare.
The file shows that you received a continuous positive airway pressure (CPAP) device from a provider who is not eligible to provide services under Original Medicare. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for the device. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on March 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the surgery is medically necessary. The Plan denied your request. The Plan says there are not enough scientific studies to show that inserting a device to open the narrowed space would be safe and effective for the enrollee.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (CPT code E2313) and electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the DME is not necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The notes state that these are needed when 2 or more actuators are being used. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. Documentation shows that the enrollee has 5/5 strength in the bilateral upper limbs except for left shoulder and elbow 4/5, left hand grip 3/5. The enrollee's upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options. Therefore, we decided that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (CPT code E2313) and electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says you have exhausted all of the plan-approved trips.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve radiofrequency ablation services. You say that this procedure is medically necessary for the enrollee's pain. The Plan denied your request. The Plan says this benefit has been exhausted.
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two radiofrequency sessions will be reimbursed per rolling 12 months. We looked at the file and Medicare rules. In this case, the enrollee has already received this procedure twice and exhausted the benefit. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (A4550, A4649) provided on April 6, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Codes A4550 and A4649 are considered bundled codes and separate payment cannot be made for these services. 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 (A4550, A4649) provided on April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (CPT code 64555) and implantable neurostimulator, pulse generator, any type (CPT code L8679) to be performed by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says this provider is not part of your network and there are back doctors in a reasonable distance to where you live.
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 percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (CPT code 64555) and implantable neurostimulator, pulse generator, any type (CPT code L8679) to be performed by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide or certified nurse assistant, providing care in the home; per hour, (S9122) provided from January 1, 2021, to January 8, 2021.

You asked the Plan to pay for the home health services. You say that when the enrollee was discharged from the hospital there were no rehabilitation facilities available to go to due to the coronavirus. You say that both of the enrollee's doctors agreed that the enrollee needed around-the-clock attention. You also say that the services should be covered. The Plan denied your request. The Plan says the provider in this case is not certified for Medicare. The Plan also says that you must receive your care from a network provider and the provider must be eligible to participate in Medicare. The Plan also says that a provider must be participating with Medicare to receive payment.

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 home health aide or certified nurse assistant, providing care in the home; per hour, (S9122) provided from January 1, 2021, to January 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and difficulty with peritoneal dialysis. Medical problems are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on November 12, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that the records support the services. The Plan denied your request. The Plan says prior authorization was not obtained.

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 podiatry services provided on November 12, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a filling (D2140), endodontic therapy (D3330), and an unspecified preventive procedure (D1999) provided on April 15, 2021.
You asked the Plan to pay an additional amount for a filling, endodontic therapy, and an unspecified preventive procedure. You say that you thought the provider was in-network and you do not agree with the charges. The Plan denied your request. The Plan says the filling and the endodontic therapy were paid at 50% of the Plan's allowed amount and you are responsible for the remainder. The unspecified preventive procedure is not a covered benefit.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a filling, endodontic therapy, and an unspecified preventive procedure have not been met. Specifically, the filling and the endodontic therapy were paid at 50% of the Plan's allowed amount and you are responsible for the remainder. The unspecified preventive procedure is not a covered benefit. Therefore, we decided that the Plan does not have to pay an additional amount for a filling (D2140), endodontic therapy (D3330), and an unspecified preventive procedure (D1999) provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral periapical radiographic images (D0220, D0230), topical application of fluoride (D1206), and periodontal maintenance (D4910) provided from February 9, 2021, through March 15, 2021.
You asked the Plan to pay for a limited oral evaluation, intraoral periapical radiographic images, topical application of fluoride, and periodontal maintenance. You say that you were unaware that the provider was out-of-network. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, intraoral periapical radiographic images, topical application of fluoride, and periodontal maintenance have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 limited oral evaluation (D0140), intraoral periapical radiographic images (D0220, D0230), topical application of fluoride (D1206), and periodontal maintenance (D4910) provided from February 9, 2021, through March 15, 2021.