Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dermatology visit (99213) to be provided by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve the out-of-network dermatology visit. You say that the services are
medically necessary. The Plan denied your request. The Plan says there are in-network providers that can
render 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 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 a
dermatology visit (99213) to be provided by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic facet joint injections (64493, 64494).
You asked the Plan to pre-approve therapeutic facet joint injections. You say that the enrollee needs this because diagnostic medial branch blocks were not successful. The Plan denied your request. The Plan says this is not supported.
The Plan must follow Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered medically reasonable and necessary for patients who have had two (2) medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used). We looked at the file and Medicare rules. The records do not show that the enrollee has had two diagnostic procedures that provided 80% pain relief. Based on this information, we decided that Medicare rules for coverage of therapeutic facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic facet joint injections (64493, 64494).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110) and the inhalation of analgesia
(D9230) provided on May 19, 2021, by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that you have been with this dentist for quite some
time and you were not aware that they were not part of your dental network. The Plan denied your request. The
Plan says the provider in question is not part of the Plan's dental network, and out-of-network dental care is not
covered.

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 does not cover dental
services received from an out-of-network provider.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services provided out-ofnetwork
are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
dental cleaning (D1110) and the inhalation of analgesia (D9230) provided on May 19, 2021, by an out-ofnetwork
provider.

Your complaint about a potential miscommunication or misunderstanding with the Plan regarding your
coverage and network 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve knee surgery (29881, 27425, 29880).
You asked the Plan to pre-approve the knee surgery. You say that the procedure is medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 knee surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the Imaging study demonstrates patella lateral tilt consistent with examination that shows lateral retinacular tenderness and crepitus. He has failed continued physical therapy for this problem. The planned procedure is retinacular release. The provided records support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. 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 knee surgery have been met. Therefore, we decided that the Plan has to pre-approve knee surgery (29881, 27425, 29880).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan
denied your request. The Plan says the requested item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266,
E0296, and E0297) is not covered; the height adjustment feature is a convenience feature.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have
to pre-approve a total electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve peroral endoscopic myotomy (POEM) and gastric
peroral endoscopic myotomy (G-POEM) procedures.
You asked the Plan to pre-approve the POEM/G-POEM procedure. You say that this surgery is supported and
would be beneficial. The Plan denied your request. The Plan says in the absence of documented achalasia, the
clinical value and effectiveness of peroral endoscopic myotomy combined with gastric peroral endoscopic
myotomy have not been demonstrated in the peer-reviewed literature, including in the setting of a hiatal hernia
with prior resection of a left esophageal diverticulum with myotomy.
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 POEM/G-POEM procedure. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee is a 74-year-old woman with gastroparesis and diabetes. The
enrollee has ineffective esophageal motility. A gastric emptying study on 4/19/21 demonstrated delayed gastric
emptying as well as possible severe esophageal dysmotility and/or distal esophageal stricture. An upper endoscopy revealed no obvious stricture; however, there was a large amount of food in the distal esophagus.
The stomach also had a large amount of food. An esophagram on 5/25/21 revealed a dilated esophagus with
decreased motility and persistent holdup of contrast in the distal esophagus.
Peroral endoscopic myotomy (POEM) is indicated for the treatment of achalasia that has failed prior
treatments. Failure of prior treatments is not documented. The documentation does not support that POEM is
medically reasonable and necessary 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 POEM/G-POEM procedure have not been met. Therefore, we decided that
the Plan does not have to pre-approve peroral endoscopic myotomy (POEM) and gastric peroral endoscopic
myotomy (G-POEM) procedures.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0425 and A0427) provided on February 27, 2021.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the member was transferred from rehabilitation to a hospital as emergency export. The Plan denied your request. The Plan says the billed code A0427 and A0425 denied due to the member being in an inpatient status during the date of service.
The Plan must follow Medicare rules. Medicare rules say that If an ambulance is used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment the ambulance trip is considered part of the DRG.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the ambulance services have not been met. Specifically, the record indicates that the member was
registered inpatient on the billed date of service. Payment for the ambulance services is included in the
payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the
Plan does not have to pay for ambulance services (A0425 and A0427) provided on February 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion services (S9328, 62368, 99602, 99601) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the home infusion services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are non-emergent. There are network providers available.

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 home infusion services (S9328, 62368, 99602, 99601) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for glasses provided on March 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for glasses. You say that you could not find where it said you had to use an in-network provider. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for 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 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. 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 glasses provided on March 22, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical records do not indicate the use of insulin injections.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
injections. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a vision examination provided on
March 24, 2021.
You asked the Plan to waive the coinsurance for the vision examination. You say that the doctor said your eyes were fine and did not mention medical issues with your eyes. The Plan denied your request. The Plan says the claim was billed correctly as a medical (diagnostic) vision exam, which is covered with a 20% coinsurance.
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 20% coinsurance for Medicare-covered vision care. You have been asked to pay 20% coinsurance for the vision examination. The vision examination falls within the Medicare-covered vision care 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 coinsurance for a vision examination provided on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical boot (L3260).

You asked the Plan to pre-approve a surgical boot. You say that the requested item is a necessity for your care.
The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not wear a leg brace. Records show that you may suffer from diabetic foot disease;
however, the item coded L3260 is not indicated for diabetic foot disease. Although orthotics may be
appropriate for you, neither Medicare nor the Plan provides coverage of the specific requested orthotics for
your condition. Therefore, we decided that the Plan does not have to pre-approve a surgical boot (L3260).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) for tooth # 18.

You asked the Plan to pre-approve the dental service. You say that this service is necessary to make sure that your implant is held firmly in place. You also say that you are on a fixed income and not afford to pay for this service. The Plan denied your request. The Plan says bone replacement graft is not listed as a covered service.

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 bone replacement graft is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft (D4263) for tooth # 18.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on February 26, 2021.

You asked the Plan to pay for the self-administered drugs. You say that your doctor advised you go to the emergency department to get a brain scan because you are on Eliquis and your doctor thought you might have had a brain bleed. The Plan denied your request. The Plan says the drugs received are the self-administered drugs.

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 pay for the self-administered drugs provided on February 26, 2021.

Benefits for the 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SelectMDx testing.
You asked the Plan to pre-approve SelectMDx testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that MolDX will review all new test/assay clinical information to determine if a test meets Medicare's reasonable and necessary requirement. Labs must submit a comprehensive dossier on each new test/assay prior to claim submission. MolDX will only cover and reimburse tests that demonstrate analytical and clinical validity, and clinical utility at a level that meets the Medicare reasonable and necessary requirement. We looked at the file and Medicare rules. The testing at issue has been evaluated by MolDX and has not been found to demonstrate analytical and clinical validity and clinical utility at a level that meets the Medicare reasonable and necessary requirement. Based on this information, we decided that Medicare rules for coverage of SelectMDx testing have not been met. Therefore, we decided that the Plan does not have to pre-approve SelectMDx testing
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 medically necessary. The Plan denied your request. The Plan says 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 record does not support the need for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care.
Additionally, the enrollee's low endurance, fatigue and pain are limiting factors for inpatient level of therapy. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection with compounded Nutria (J3411, J3415, J3420, J3490) provided on October 8, 2020, and electrical stimulation (unattended), to one or more areas for indication(s) other than wound care (G0283) provided on October 15, 2020.

You asked the Plan to pay for an injection with compounded Nutria and an electrical stimulation (unattended). You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, NOC code. 

In this case, the CPT Code Manual definition of code G0283 is "Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care." 

We asked our coder 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 an injection with compounded Nutria and an electrical stimulation (unattended). Our reviewer says that the use of code G0283 is not supported by the records provided for date of service October 15, 2020. Our reviewer found that the use of code G0283 is not supported as records indicate the procedure was attended. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an injection with compounded Nutria and an electrical stimulation (unattended) have not been met. In addition, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using a NOC code. As this compounded drug was not billed properly, payment cannot be made Therefore, we decided that the Plan does not have to pay for an injection with compounded Nutria (J3411, J3415, J3420, J3490) provided on October 8, 2020, and electrical stimulation (unattended), to one or more areas for indication(s) other than wound care (G0283) provided on October 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional transportation trip in excess of 50 miles.
You asked the Plan to pre-approve the transportation trip. You say that the trip is medically necessary. The Plan denied your request. The Plan says the trip exceeds the plan benefit.
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 routine transportation when the trip is less than 50 miles. 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.
The trip exceeds the 50 miles limit. Therefore, we decided that the Plan does not have to pre-approve an additional transportation trip in excess of 50 miles