Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) and prophylaxis (D1110) provided on January 10, 2020 by an out of network provider.You asked the Plan to pay forthe dental services. You say that in the past, under your spouse's insurance, services from this provider have been covered. You say that you were not aware that the provider was not in network. You also say that you thought you would get partial coverage.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that services are only covered when received by a participating 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.Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not covered when you receive them outof network.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) and prophylaxis (D1110) provided on January 10, 2020 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device and has unique characteristics that preclude the trial of the basic pump.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar infusion (22853, 22840 and 22558).
You asked the Plan to pre-approve the lumbar infusion. You say that you would like reconsideration because your back pain is becoming more disabling over time. The Plan denied your request. The Plan says criteria requires patient's to be abstinent from tobacco use for at least six weeks prior to the lumbar infusion to increase the odds for success as much as possible.
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 lumbar infusion. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records indicate that you are a smoker and there is no documentation of smoking cessation. 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 lumbar infusion have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar infusion (22853, 22840 and 22558).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat epidural steroid injections (62323).
You asked the Plan to pre-approve the repeat injections. You say that you would like reconsideration because these injections help to reduce the pain in your legs for a period of time. The Plan denied your request. The Plan says you have only experienced 25% relief from prior injections and there is no adequate radiologic imaging or conservative treatment failures.
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 repeat injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you did not achieve the level of pain relief from the prior injection. 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 repeat injections have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat epidural steroid injections (62323).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion spacer device.
You asked the Plan to pre-approve the Superion spacer. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the Superion spacer devices are still being studied to see if this treatment is reasonable and necessary to be covered by Medicare.
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 Superion spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer remains experimental and more research is needed. 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 Superion spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion spacer device.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for needle electromyography (95861) provided on November 6, 2019.
You asked the Plan to pay for the needle electromyography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the documentation did not include documentation of electromyography performed with needles.
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 95861 is needle electromyography; 2 extremities with or without related paraspinal areas. 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 needle electromyography. Our reviewer says that CPT code 95861 meets criteria for billing or reimbursement consideration. Our physician reviewer found the documentation indicates that bilateral, lower extremity, free running EMGs were monitored during surgery. The needles used for this monitoring are very small and often embedded in an electrode that is applied to the area to be monitored. The electrode is applied once and left in place for the procedure. Stating that "electrodes were applied" rather than stating "needles were inserted" would not constitute the absence of needles. 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 needle electromyography have been met. Therefore, we decided that the Plan has to pay for needle electromyography (95861) provided on November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Novocure Optune device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary for the treatment of glioblastoma. The Plan denied your request. The Plan says the tumor is not supratentorial.
The Plan must follow Medicare rules. Medicare rules say that tumor treatment field therapy is covered when there is evidence of a newly diagnosed supratentorial glioblastoma. 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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found this should remain denied, as the tumor is not supratentorial. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Novocure Optune device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ZILRETTA.
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 the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee pain and bilateral knee osteoarthritis, confirmed by x-rays. She had ZILRETTA injections on January 16, 2020 and repeat injections are now requested. The safety and efficacy of repeat administration of ZILRETTA is not demonstrated. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve ZILRETTA.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from August 13, 2019, to August 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider from August 13, 2019, to August 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650), a shoulder-hand-wrist orthosis (L3960), and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 6, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650), a shoulder-hand-wrist orthosis (L3960), and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sales tax (S9999) for items purchased on April 12, 2019.
You asked the Plan to pay for sales tax. You say that you were injured while on vacation so this should be covered. The Plan denied your request. The Plan says sales tax is not covered under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that additional payment cannot be made for sales taxes. We looked at the file and Medicare rules. The requested payment for sales tax is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of sales tax have not been met. Therefore, we decided that the Plan does not have to pay for sales tax (S9999) for items purchased on April 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services (callus paring) you received on December 26, 2019.
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. The records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care 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 podiatry services (callus paring) you received on December 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says a safer environment and appropriate care can be provided at a lower level than inpatient SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95861) and train of four testing (95999) provided on August 1, 2019.
You asked the Plan to pay for needle electromyography and train of four testing. You say that this should be reprocessed. The Plan denied your request. The Plan says these codes are 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 95861 is needle electromyography; 2 extremities with or without related paraspinal areas. 95999 is an unlisted neurological or neuromuscular diagnostic procedure. 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 needle electromyography and train of four testing. Our reviewer says that the billing of CPT 95861 and 95999 is not supported. Our physician reviewer found the documentation clearly states that needle monitoring was performed in one extremity. While the documentation notes that two units should be billed, this is vague as to whether or not two extremities were monitored or the monitoring was performed twice. Train of four monitoring does not have its own billing code and is considered to be part of the overall monitoring code. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography and train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95861) and train of four testing (95999) provided on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64635).
You asked the Plan to pre-approve the injections. You say that you would like reconsideration because you have back pain and were advised by your pain management provider that you would be a good candidate for facet joint injections. The Plan denied your request. The Plan says there were no records submitted to support that you have had conservative treatment for lower back pain.
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 injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no recent imaging and radiofrequency ablation of the lateral sacral branches is considered experimental/investigational. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64635).
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. The Plan denied your request. The Plan says the enrollee is not expected to improve from LTACH care.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for acute-on-chronic respiratory failure. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on July 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the radiology services provided out of network. You say that the out of network provider is approved by Medicare. You say that there is no option given to patients at the nursing facility to find a participating provider. You say that the services provided fall under the plan's contract with the nursing home and should be paid just as any other service provided by the nursing home. The Plan denied your request. The Plan says enrollee's must use in-network provider to get medical care and services. The Plan says that the only exceptions are emergency care or urgently needed services that the enrollee gets from an out of network provider.
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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the radiology services provided on July 15, 2019 by an out of network (OON) provider.