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

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
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 Eliquis.
Benefits for these services 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI and an MRA provided on November 16, 2020.
You asked the Plan to waive the copayment for an MRI and an MRA. You say that you were advised by the Plan as well as the provider, that you would not have a copayment for an MRI or an MRA. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $75 copayment for each outpatient diagnostic test and therapeutic services and supplies.
You have been asked to pay a $75 copayment for an MRI and an MRA ($75 x 2 tests = $150). The EOC is clear that there is a $75 copayment for each of the tests at issue. The records show that you were not billed a copay for the additional MRI. An MRI and an MRA fall within the outpatient diagnostic tests and therapeutic services and supplies 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 a magnetic resonance imaging (MRI) of the brain (70551) and a magnetic resonance angiography (MRA) of the head (70544) provided on November 16, 2020.
Your complaint about potentially receiving misinformation from the Plan or the provider, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. 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 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 basedon 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 do not require treatmentby multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950), porcelain/ceramic pontic (D6245) and a retainer crown (D6740).
You asked the Plan to pre-approve the dental services. You say that you were told that all treatments and procedures related to one root canal and crown would be covered. The Plan denied your request. The Plan says the requested core buildup and fixed bridgework services are not covered by the dental 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup (D2950), porcelain/ceramic pontic (D6245) and a retainer crown (D6740).
Your complaint about a possible miscommunication from the Plan 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: 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 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 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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 acute inpatient rehabilitation facility (IRF) admission and services.
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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. 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 a stroke. Medical conditions 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, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational
therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services
can be provided in a different 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 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 shoulder elbow wrist hand orthosis provided on June 15, 2020.
You asked the Plan to pay for the shoulder elbow wrist hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation does not support that the enrollee's medical condition requires the billed equipment.
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 pay for the shoulder elbow wrist hand orthosis (L3960). Our reviewer says that the shoulder elbow wrist hand orthosis is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal a detailed objective right shoulder physical examination that indicates a need for the requested orthosis. The requested L3960 exceeds the patient's medical need. The provider notes that the brace is to support weak muscles, improve function and decrease pain but the documentation does not reveal a detailed neuromuscular exam indicating objective weakness of the right arm. There is no evidence of a recent surgery or injury to the right shoulder. It is unclear how wearing an airplane style orthosis will assist in improving patient's activities of daily living. It is also unclear why the patient requires this style of splint. There is no evidence of axillary contracture, burn injury, or other indication for this orthosis. 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 shoulder elbow wrist hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 6, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed 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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. 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 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 as LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 

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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Vertiflex Superion Interspinous Device.You asked the Plan to pre-approvethese services. You say that these services are medically necessary.The Plan denied your request. The Plan says that medical studies haven't proven that the device is helpful for treatment of your health problem.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and applythe 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 spacer is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that your condition does not meet Medicare criteria for 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-approvethe Vertiflex Superion Interspinous Device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (99202) provided on March 1, 2021.

You asked the Plan to pay for the services. You say that this should be covered. The Plan denied your request. The Plan says this is not a covered service.

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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (99202) provided on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora periodic oral evaluation (D0120), teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on January 25, 2021.You asked the Plan to pay fora periodic oral evaluation, teeth cleaning, and bitewing radiographic images. You say that you do not want to change providers.The Plan denied your request. The Plan says you are not covered for these services 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 periodic oral evaluation, teeth cleaning, and bitewing radiographic images have not been met. Specifically, services were provided by an out-of-network provider. 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 fora periodic oral evaluation (D0120), teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on January 25, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the spacer placement is medically necessary. The Plan denied your request. The Plan says this procedure is considered investigational and is not covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guidelines and peer reviewed literature do not fully support the spinal decompression device procedure over traditional lumbar laminectomy. There is a lack of large volume, long-term, peer-reviewed outcome studies to support the use of this 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided on January 7, 2021.
You asked the Plan to pay for therapeutic activities. You say that this should be covered. The Plan denied your request. The Plan says there is a more appropriate code for the service provided.
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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the service provided was performed by a qualified occupational therapist assistant in a home health setting. There is a more appropriate code for this service. Based on this information, we decided that Medicare rules for
coverage of therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided on January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system for the enrollee.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this feature is not covered by Medicare because it is not primarily medical in nature.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea follow-up visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea follow-up visit. You say that you would like to see this out-of-network provider.The Plan denied your request. The Plan says there are in-network providers available who can provide these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has topre-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-approvea follow-up visit to be provided by an out of network (OON) provider