Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of a modality to 1 or more areas; electrical 
stimulation (manual), each 15 minutes 96372- Therapeutic, prophylactic, or diagnostic injection (specify 
substance or drug); subcutaneous or intramuscular, 97112- Therapeutic procedure, 1 or more areas, each 15 
minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities, 97016- Application of a modality to 1 or more areas; 
vasopneumatic devices, J3411- Injection, thiamine HCl, 100 mg, J3415- Injection, pyridoxine HCl, 100 mg, 
J3420- Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg, J1955- Injection, levocarnitine, per 1 g. 
 
You asked the Plan to pre-approve application of a modality to 1 or more areas; electrical stimulation (manual), 
each 15 minutes 96372- Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); 
subcutaneous or intramuscular, 97112- Therapeutic procedure, 1 or more areas, each 15 minutes; 
neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities, 97016- Application of a modality to 1 or more areas; 
vasopneumatic devices, J3411- Injection, thiamine HCl, 100 mg, J3415- Injection, pyridoxine HCl, 100 mg, 
J3420- Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg, J1955- Injection, levocarnitine, per 1 g. You 
say that the services are covered by Medicare. The Plan denied your request. The Plan says here are multiple 
providers (over 100) within the members network that can provide Electric Stimulation, Neuromuscular Re-
education, Vaso-pneumatic therapy. For the SQ Vitamin Blend, unable to find any criteria or literature to 
support this request to be used along with therapy for chronic pain and neuropathy. 
 
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 Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the Electric Stimulation, Neuromuscular Re-education, Vaso-pneumatic therapy at 
issue in this appeal. Medicare does not cover naturopathic services. 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 
approve application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes 96372- 
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular, 
97112- Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, 
balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, 
97016- Application of a modality to 1 or more areas; vasopneumatic devices, J3411- Injection, thiamine HCl, 
100 mg, J3415- Injection, pyridoxine HCl, 100 mg, J3420- Injection, vitamin B-12 cyanocobalamin, up to 
1,000 mcg, J1955- Injection, levocarnitine, per 1 g.