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

We decided that the Plan does not have to pay for the injection (96732) provided on September 29, 2020.
You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested service is not a Medicare covered benefit with the information provided.
The Plan must follow Medicare rules. Medicare rules say that in order for physician-provided drugs to be covered, the medical records must document the name of the drug administered as well as the dosage. The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection
(specify substance or drug); subcutaneous or intramuscular. Payment for HCPCS/CPT code 96372 is 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. Therefore, we decided that the Plan does not have to pay for the injection (96732) provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that you would like to continue to see this provider. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan
denied your request. The Plan says Medicare coverage criteria are not 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 based on
review of the available records, the enrollee does not meet CMS coverage criteria for an IRF admission.
The enrollee is medically stable. The enrollee does not require a physician supervision 3 times per week for the
ongoing management of any active or acute exacerbations of chronic medical conditions.
There is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent
physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee can be easily be
treated at a less intense and alternate 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 pre-approve the select comfort bed (E1399). 
 
You asked the Plan to pre-approve the bed. You say that you purchased a sleep number bed out of pocket 
several years ago, but it has worn out. You need a new bed and would like the Plan to cover it. The Plan denied 
your request. The Plan says this item is considered a comfort and/or convenience item and is not covered. The 
supplier is not a Medicare approved supplier. 
 
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 the select comfort bed (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platform or roll about crutch.
You asked the Plan to pre-approve a platform or roll about crutch. You say that you cannot use crutches or a
wheelchair and this roll about crutch is medically necessary. The Plan denied your request. The Plan says this
item is not covered by Medicare.
The Plan must follow Medicare rules. The rules specifically state that this equipment is not covered by
Medicare. Therefore, we decided that the Plan does not have to pre-approve a platform or roll about crutch.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Gelnique.

You asked the Plan to pre-approve Gelnique. You say that the requested drug is a necessity for your care. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Gelnique.

Benefits for Gelnique 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Osteoplasty, facial bones; augmentation (autograft, 
allograft, or prosthetic implant) (CPT code 21208), for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that you are requesting osteoplasty due to facial 
atrophy due to a long history of human immunodeficiency virus (HIV) and the right side of the enrollee's face 
looks and feels larger than the left. The Plan denied your request. The Plan says the request is not reasonable 
and necessary and is cosmetic in nature. The Plan states their review says that facial lipoatrophy is a common 
side effect of HIV treatment and characterized by facial volume loss; however, this does not cause functional 
impairment. 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 surgery have not been met. There were no 
reports of problem with function of the enrollee's eyes, ears, nose or mouth. There are no reports of a severe 
problem with the enrollee's face. This is cosmetic surgery. Therefore, we decided that the Plan does not have to 
pre-approve Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) (CPT code 
21208), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the kyphoplasty.

You asked the Plan to pre-approve the kyphoplasty. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says the documentation submitted does not support that the compression fracture is less than 12 weeks old.

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 kyphoplasty. Our reviewer says that criteria for a kyphoplasty are not met. Our physician reviewer found the medical records do not clearly show that these are new fractures that are less than 12 weeks old.

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 kyphoplasty have not been met. Therefore, we decided that the Plan does
not have to pre-approve the kyphoplasty.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept Procedure.

You asked the Plan to pre-approve the Intracept Procedure. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says this service is not medically reasonable and 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 Intracept Procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental for the treatment of back pain. More research is needed to show its safety and efficacy. 

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 Intracept Procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept Procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower back surgery including fusion at lumbar-sacral level L5-S1.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a new request may be submitted with a negative smoking result, or if there is new clinical information of neurologic change.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records show that the enrollee is a smoker, and has not stopped smoking. Smoking is a contraindication to spinal fusion. 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 lower back surgery including fusion at lumbar-sacral level L5-S1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).

You asked the Plan to pre-approve the dental service. You say that the partial denture is medically necessary. The Plan denied your request. The Plan says the enrollee's masticatory function does not appear to be severely impaired.

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. The Plan covers the dental service when the services are medically necessary and reasonable.

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 dental service. Our reviewer says that partial lower denture is not medically necessary. Our physician reviewer found the provided documentation indicates that a single mandibular tooth, #19, would be replaced. The reviewer found that tooth #18 has partially drifted into the missing tooth space. The reviewer also found that the enrollee's masticatory function would not be appreciably increased with the replacement of tooth #19. Therefore, the reviewer found that a partial lower denture is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, the file does not indicate that the enrollee's masticatory function would be appreciably increased with the replacement of the tooth. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation feature (E2300).
You asked the Plan to pre-approve the power seat elevation feature. You say that the service should be covered. The Plan denied your request. The Plan says the power seat elevation feature is non-covered.
The Plan follows Medicare rules. Medicare rules say that power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve power seat elevation feature (E2300).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the auricular stimulator for the enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says there have not been large enough quality studies to support efficacy and safety. 
 
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is 
not a covered Medicare benefit. 
 
We looked at the file, and Medicare rules. The requested stimulator is not a covered benefit under Medicare 
rules. Based on this information, we decided that Medicare rules for coverage of an auricular stimulator have 
not been met. Therefore, we decided that the Plan does not have to pre-approve the auricular stimulator for the 
enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve an office visit with an out-of-network provider. You say that the requested 
doctor has managed your medical condition in the past. The Plan denied your request. The Plan says you can 
get the care you need within the health plan 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test (G0480) provided on April 1, 2021, by an out-of-network
(OON) provider.
You asked the Plan to pay for a drug test. You say that you were not aware of the requirement of obtaining a
prior authorization for the member's plan type. You also say the testing was medically necessary. The Plan
denied your request. The Plan says services were provided 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 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. The records provided for review do not show that the services at issue were urgent or
emergent. 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 a drug test (G0480) provided on April 1, 2021, by an out-of-network
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (64636, 64635).

You asked the Plan to pre-approve lumbar radiofrequency ablation. You say that the previous procedures were
not bilateral. The Plan denied your request. The Plan says the session limit applies regardless of laterality.

The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two
(2) radiofrequency sessions will be reimbursed per rolling 12 months.

We looked at the file and Medicare rules. The records show that the enrollee has had two radiofrequency
sessions within the past 12 months. Based on this information, we decided that Medicare rules for coverage of
lumbar radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to preapprove
lumbar radiofrequency ablation (64636, 64635).
Appeal type: DME/ Orthotics
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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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 pre-approve the Vertiflex Superion, insertion of 
interlaminar/interspinous process stabilization/distraction device (22869). 
 
You asked the Plan to pre-approve the Vertiflex Superion device. You say that this treatment is medically 
necessary and appropriate for this stage of the disease progression. The Plan denied your request. The Plan says 
Vertiflex is considered experimental and investigational. There is not enough studies on Vertiflex superion to 
show it is safe and effective. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex Superion, insertion of interlaminar/interspinous process 
stabilization/distraction device (22869).
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the office visit. We decided that the Plan does not
have to waive the copayment for the telehealth service.

You asked the Plan to waive the copayment for the office visit. You say that you would like reconsideration
because there was no office visit on April 15, 2020, and the visit on April 16, 2020, was not in person but
through telemed. The Plan says that the copayments you are being charged are correct.

We decided that the Plan has to waive the copayment for the office visit.

The Plan follows Medicare rules. Medicare rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

We looked at your request, the file and the rules. Based on this information, we determined that Medicare
coverage criteria for the office visit have been met. Specifically, the Plan has not made reasonable and diligent
efforts to gather and forward to us information regarding their decision to deny your request. In your appeal,
you state that you never went to the office. The Plan has not forwarded any medical records or clinical
information to verify that these services were rendered. It is the burden of the Health Plan to substantiate their
denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we
decided that the Plan has to waive the copayment for the office visit.

We also decided that the Plan does not have to waive the copayment for the telehealth service.

The Plan follows Medicare rules. Medicare rules say that a plan must disclose to its enrollees in clear, accurate
terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan contract says
that enrollees must pay a $45 copayment for each visit for physician/practitioner services, including doctor's
office visits with a specialist.

You have been asked to pay a $45 copayment for telehealth services with a specialist. The records show you
had a telehealth visit on April 15, 2020. The EOC confirms $45 is the required copayment for this service. A
telehealth visit falls within the physician/practitioner services, including doctor's office visits 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 telehealth service.

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.