Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a home ventilator (E0466) provided on September 15, 2019.
You asked the Plan to pay for the home ventilator. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for a home ventilator (E0466) provided on September 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a carpal tunnel surgery (64721)
provided on December 31, 2019.
You asked the Plan to pay for surgical assistant services. You say that this was medically necessary and should
be processed as in-network. The Plan denied your request. The Plan says surgical assistant services are not
covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code
64721. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based
upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met.
Therefore, we decided that the Plan does not have to pay for surgical assistant services on a carpal tunnel
surgery (64721) provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nutritionist services provided on January 22, 2020.
You asked the Plan to pay for the nutritionist services. The Plan denied your request. The Plan says nutritional
services received from out of network providers are not covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for nutritionist services provided on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulpal debridement provided on December 17, 2019.
You asked the Plan to pay for the pulpal debridement. You say that this provider took an x-ray and confirmed the previous examination. You also say that this provider wrote you a prescription to help with the pain that your abscessed tooth caused. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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 for the pulpal debridement provided on December 17, 2019.
Your complaint about your dissatisfaction with the initial 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a peripheral nerve or branch injection (64450) provided on
February 6, 2020.
You asked the Plan to pay for a peripheral nerve or branch injection. You say that this service is supported in
the records. The Plan denied your request. The Plan says this procedure is not covered.
The Plan follows Medicare rules. Medicare rules say that peripheral nerve blocks will be considered medically
reasonable and necessary for the above listed conditions.
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 a peripheral nerve or branch injection. Our
reviewer says that this procedure was not medically necessary. Our physician reviewer found the records do not
show that the enrollee had a covered indication for this service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a peripheral nerve or branch injection have not been met. Therefore, we decided
that the Plan does not have to pay for a peripheral nerve or branch injection (64450) provided on February 6,
2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections, 16 units, once every week, for 3
weeks.
You asked the Plan to pre-approve the injections. You say that the enrollee would benefit from the use
of Synvisc injections to provide Visco supplementation. The Plan denied your request. The Plan says that
Synvisc injections are subject to step therapy. The Plan also says documentation supporting the medical
necessity of the injections was not provided.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 drug is not medically necessary. Our physician reviewer found the documentation
provided does not show that the enrollee trialed and failed Orthovisc and Monovisc. The reviewer also found
that the documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less
effective, or would likely have adverse effects for the enrollee in this case.
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 injections, 16 units, once every week, for 3 weeks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) provided on July 4, 2019.You asked the Plan to pay for critical care. You say that the medical records show this service was performed.The Plan denied your request. The Plan says this code is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.We find that CPT code 99291 is not supported in the medical record. Specifically, this is a time-based code, and the records do not document the time spent on this service. Based on this information, we decided that Medicare rules for coverage of critical care have not been met.Therefore, we decided that the Plan does not have to pay for critical care (99291) provided on July 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services provided on
September 6, 2019 and September 18, 2019.
You asked the Plan to waive the copayment for the podiatry services. You say that you feel you should not be
responsible for this cost sharing amount and you would like the Plan to reconsider your request. The Plan
denied your request. The Plan says you received podiatry services on the dates of service at issue in this appeal.
The Plan says that the correct copayments have applied per your contract with the Plan.
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 $30
copayment for Podiatry services.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received podiatry care on
September 6, 2019 and September 18, 2019. You have been asked to pay a $30 copayment for each podiatry
visit. The podiatry visits fall within the Podiatry services 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 podiatry services provided on September 6, 2019 and September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse you for orthotics provided by the contract provider on November 4, 2019.You asked the Plan to reimburse you for the shoe inserts. You say that you were told the orthotics were covered.The Plan denied your request. The Plan says that orthotics are only covered for patients with diabetic foot disease or for patients who wear a leg brace.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were referred for the shoe inserts by a contract provider. The file does not show that the Plan provided notice that the shoe inserts would not be covered. Under Medicare rules, this means the shoe inserts are considered approved by the Plan.Therefore, we decided that the Plan has to reimburse you for orthotics provided by the contract provider on November 4, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on November 18, 2019.You asked the Plan to pay for the paramedic intercept services. You say that the services were medically necessary.The Plan denied your request. The Plan says this item is not a covered benefit.The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area.Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on January 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 you by an out-of-network provider on
January 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT Scan of the chest.You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration as this service is medically necessary.The Plan denied your request. The Plan says CT of chest is not medically indicated without further clinical information.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT Scan. Our reviewer says that there is no documentation of a recurrence based on member complaints, exam findings or laboratory testing. Our physician reviewer found routine monitoring via imaging after three years is not 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 the CT Scan have not been met.Therefore, we decided that the Plan does not have to pre-approve a CT Scan of the chest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on December 27, 2019.You asked the Plan to pay for the lumbar-sacralorthosis. You say that you would like reconsideration because the back brace was medically necessary.The Plan denied your request. The Plan says the documentation submitted does not include a valid physician's order.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 lumbar-sacral orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a credible physical examination of the back.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-sacral orthosis have not been met.Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on December 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pregablin capsules.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because these drugs are not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Pregablin capsules.
Benefits for self-administered drugs 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spravato.
You asked the Plan to pre-approve the Spravato. You say that you would like reconsideration because this drug is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says this drug is not appropriate because the member has a history of substance abuse.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Spravato. Our reviewer says that this member does not meet the criteria for the use of Spravato due to the black box warning. Our physician reviewer found the black box warning on Spravato limits the use in patients with known history of substance use. 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 Spravato have not been met. Therefore, we decided that the Plan does not have to pre-approve Spravato.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transport taxi (A0100) provided January
24, 2020.
You asked the Plan to pay for the non-emergency transport taxi. You say that this trip was obviously to an
urgent care and contractually should be paid. The Plan denied your request. The Plan says the claim processed
correctly as the provider billed with an invalid place of treatment code.
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 36 one-way, non-emergency trips to plan-approved locations within the plan service
area.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the
Plan does not have to pay for the non-emergency transport taxi (A0100) provided January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01992) provided on November 14, 2019.You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because the member requested the anesthesia services.The Plan denied your request. The Plan says this service was not medically 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 pay for the anesthesia services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, for sacroiliac injectors, the use of moderate sedation is usually unnecessary. Documentation must clearly establish the need for such sedation in the specific patient.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 anesthesia services have not been met.Therefore, we decided that the Plan does not have to pay for anesthesia services (01992) provided on November 14, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.You asked the Plan to pre-approve the injections. You say that this is medically necessary.The Plan denied your request. The Plan says the records provided do not show the results of an examination done by the provider confirming pain is coming the facet joints between the neck and lower back.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 injections are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no physical exam, only a telemedicine visit. There is no clear documentation of facet loading tests and degree of limitation of the lumbar spine. Therefore, the criteria of the LCD are not met and the request is considered not medically reasonable or 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 the injections have not been met.Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on November 11,
2019.
You asked the Plan to waive the deductible for an office visit. You say that you disagree with the charges. The
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the
correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible for out-of-network physician/practitioner services,
including doctor's office visits.
You had an office visit on November 11, 2019 with an out-of-network provider. Therefore, you are responsible
to pay your share of the out-of-network charges. The record shows that you had paid $334.42 toward the $750
deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $41.01.
The item or service you asked the Plan to waive the deductible for falls within the benefit category
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $750 deductible for out-of-network physician/practitioner services,
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an
office visit was received on November 11, 2019. Therefore, we decided that the Plan does not have to waive
the deductible for an office visit provided on November 11, 2019.