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

 
We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to preapprove the CGM. You say that the enrollee has a condition that precludes them from 
pricking their fingers. The Plan denied your request. The Plan says the enrollee is not using insulin three or 
more times per day and their insulin dosing does not require frequent adjustments. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess 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 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM 
have not been met. Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous 
glucose monitor (CGM).
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 ending in the current facility, however you are not ready to go home. You say that IRF care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive the care needed in another setting.

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a tib-fib fracture and was transferred to skilled nursing where he is receiving care for a right heel wound. He is now able to weight bear. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on June 8, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0483 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 G0483 is definitive drug testing, 22 or more drug classes. 
 
 
 
 
  
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records support that 18 
drug classes were tested. 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 pay for the drug testing 
rendered on June 8, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on July 30, 2021. 
 
You asked the Plan to waive the copayment for emergency care. You say that you waited over three hours and 
then left without being seen. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 
copayment for emergency care.  
 
The medical records show that you were checked in and vitals were taken at the emergency room on July 30, 
2021. Therefore, you are responsible to pay the $65 copayment.  
 
You have been asked to pay a $65 copayment for emergency care. Emergency care falls within the emergency 
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 copayment for emergency care provided on July 
30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional physical therapy visits (97110). 
 
You asked the Plan to pre-approve two additional physical therapy visits. You say that the enrollee requires 
two additional physical therapy visits. The Plan denied your request. The Plan says since the enrollee's 
disability score has improved and the enrollee is progressing with activities, it appears that skilled therapy 
services are no longer necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.  
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 two additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found in this case, the member has previously 
been treated with outpatient therapies and should be independent with a home exercise program. There is no 
documentation of a recent injury or decline in function. The additional therapy services are not an appropriate 
duration and frequency for treatment of the member's medical condition and therefore are 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 two additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve two additional physical therapy visits (97110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia ? first 15 minutes 
(D9222) and deep sedation/general anesthesia ? each subsequent 15-minute increment (D9223). 
 
You asked the Plan to pre-approve deep sedation/general anesthesia. You say that you require sedation for the 
dental procedure to be performed. The Plan denied your request. The Plan says you do not meet criteria for 
sedation. 
 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 deep 
sedation/general anesthesia when the services are medically necessary and reasonable as defined in the Plan?s 
coverage criteria outlined in the Medicare rules section of this letter.  
 
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 deep sedation/general anesthesia. Our 
reviewer says that deep sedation/general anesthesia is not medically necessary. Our physician reviewer found 
that a review of the enrollee's medical and dental record indicates that tooth #3 is indicated for extraction. The 
tooth is erupted and there was no indication of severe infection. There was no indication in the enrollee's 
medical history that would contraindicate the use of local anesthesia for the procedure. The documentation 
provided does not meet the criteria for coverage for the use of deep sedation, general anesthesia for the 
extraction of tooth #3. 
 
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 deep sedation/general anesthesia have not been met. Therefore, we decided that 
the Plan does not have to pre-approve deep sedation/general anesthesia  first 15 minutes (D9222) and deep 
sedation/general anesthesia  each subsequent 15-minute increment (D9223).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.

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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is considered experimental in nature, as more research is needed to support efficacy. 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 an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dry needling naturopathy services provided from March 18, 
2021, to May 14, 2021. 
 
You asked the Plan to pay for naturopathy services. You say that you should not be responsible for payment of 
these denied services. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because naturopathy services are not covered under any conditions. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for dry needling naturopathy services provided from March 18, 2021, to May 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that this is needed to reduce swelling. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a soft appliance occlusal guard (D9945). 
 
You asked the Plan to pre-approve an occlusal guard. You say that you have broken two teeth due to grinding 
at night and need this guard to protect your other teeth. The Plan denied your request. The Plan says this item is 
not covered by your dental benefit. 
 
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 pre-approve a 
soft appliance occlusal guard (D9945).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left knee genicular nerve block.

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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis and has not responded to corticosteroid injections of Synvisc. Genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational and not medically necessary for the treatment of chronic knee pain. 

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 a left knee genicular nerve block.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 14, 2021. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says the benefit is 
available under Medicare Hospice. 
 
  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic porcelain fused to high noble metal (D6240) and a retainer crown (D6750) by a contracted provider.

You asked the Plan to pre-approve a pontic porcelain fused to high noble metal and a retainer crown. You say that you have a lot of pain eating and it is causing your other teeth to shift. You also say you have to take several pain medicines for this issue. The Plan denied your request. The Plan says this service is not a covered benefit.

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 pre-approve a pontic porcelain fused to high noble metal (D6240) and a retainer crown (D6750) by a contracted provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) and comprehensive audiometry evaluation (92557) provided on July 20, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the specialist visit. You say that you did not know the hearing company was not covered or that you had to have a doctor's letter. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. CPT code 99203 denied due to services not being permitted by an audiologist.

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. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

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 the outpatient office visit (99203) and comprehensive audiometry evaluation (92557) provided on July 20, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the third surgical extraction (D7210) provided on March 17, 
2021. 
 
You asked the Plan to pay for the extraction. You say that tooth #29 was non-restorable and required 
extraction. The Plan denied your request. The Plan says extractions are covered at a frequency limitation of two 
procedures per calendar year. The Plan also says that this service exceeds the maximum count allowed per 
period. 
 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, extractions are limited to two 
procedure codes per calendar year. The record shows that the enrollee received three surgical extractions 
(D7210 x3) on March 17, 2021, two of which were covered by the Plan, and the enrollee's extractions benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pay for the third surgical extraction 
(D7210) provided on March 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for X-ray imaging (74018, 71045) provided on August 28, 2019.

You asked the Plan to pay for X-ray imaging. You say that the services at issue were a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for X-ray imaging was not filed until July 2, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for X-ray imaging (74018, 71045) provided on August 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor sensors 
(K0553) for the enrollee. 
 
You asked the Plan to pre-approve the sensors. You say that these are medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the enrollee does not receive at least 3 insulin injections per day. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and supplies are considered 
medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily 
administrations, 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 assess 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 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle 
Libre continuous glucose monitor sensors (K0553) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve laboratory services. You say that this is medically necessary. The Plan denied your request. The Plan says this is available in-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 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 laboratory services to be provided by an out-of-network (OON) provider.