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

We decided that the Plan does not have to pay for chiropractic maintenance care (98941) provided from August 25, 2021, to October 19, 2021.

You asked the Plan to pay for chiropractic maintenance care. You say that these services were previously covered. The Plan denied your request. The Plan says these services are non-covered maintenance care.

The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover chiropractic maintenance care. The rules also say that claims submitted for Chiropractic Manipulative Treatment codes 98940, 98941, or 98942 must contain an AT modifier or they will be considered not medically necessary. 

We looked at the file and Medicare rules. The records indicate that these services were maintenance care, and these services were not billed with an AT modifier to indicate active treatment. Based on this information, we decided that Medicare rules for coverage of chiropractic maintenance care have not been met.

Therefore, we decided that the Plan does not have to pay for chiropractic maintenance care (98941) provided from August 25, 2021, to October 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapy (PT) provider.

You asked the Plan to pre-approve these services. You say that this provider is close to your residence. The Plan denied your request. The Plan says the services are available from network providers.

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. The network providers are within four miles of your residence. 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 a referral to an out-of-network physical therapy (PT) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics (L3000).  You asked the Plan to pre-approve foot orthotics. You say that you need this to be able to walk. The Plan denied your request. The Plan says this item is not a covered benefit for your condition.  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 suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Praluent injections.  You asked the Plan to pre-approve Praluent injections. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Praluent injections are not covered under the enrollee's Medicare Part B benefit.  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 Praluent injections.   Benefits for Praluent injections 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve physical therapy. You say that you would like the Plan to approve these services. The Plan denied your request. The Plan says there are in-network physicians who can provide the requested 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 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 physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 2, 4, 6, 17, and 20, and pontics (D6251) for teeth # 3, 5, 18, and 19.  You asked the Plan to pre-approve retainer crowns and pontics. You say that your current bridge is broken. You say that it needs to be removed and repaired before it gets any worse. You also say that you are worried about an infection and further damage. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontics are not listed as covered services either.  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 retainer crowns and pontics are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 2, 4, 6, 17, and 20, and pontics (D6251) for teeth # 3, 5, 18, and 19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve removal of an impacted tooth, partially bony (D7230) for tooth # 32, and  You asked the Plan to pre-approve removal of an impacted tooth. You say that your wisdom tooth is cracked in half. You say that this tooth needs to be extracted. You also say that you are in extreme pain. The Plan denied your request. The Plan says removal of an impacted tooth, partially bony, 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 removal of an impacted tooth, partially bony, is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of an impacted tooth, partially bony (D7230) for tooth # 32, and
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 criteria is not met.

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 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 4, 2021, to August 10, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were admitted to the hospital within 30 days of you leaving. The Plan denied your request. The Plan says the correct copayment has been applied.  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 $300 copayment for inpatient hospital care/inpatient hospital care.   You have been asked to pay a $300 copayment for an inpatient hospital stay. The correct copayment has been applied to the inpatient stay that was provided. An inpatient hospital stay falls within the inpatient hospital care/inpatient hospital 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 an inpatient hospital stay provided by a participating provider on August 4, 2021, to August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous device (22869).  You asked the Plan to pre-approve insertion of interlaminar/interspinous device. You say that you strongly believe that coverage should be provided. By not providing coverage, this Plan is out of compliance with Medicare guidelines. The Plan denied your request. The Plan says this service is considered experimental, investigation and/or unproven. Research has not found it to be helpful for the enrollee's condition or for what is causing pain.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.   We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous device (22869).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a repeat Zilretta injection.  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 bilateral primary osteoarthritis of the knee and had a Zilretta injection on January 13, 2022. The efficacy and safety of repeat administration has not been demonstrated. The repeat injection is 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 a repeat Zilretta injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Injectafer (J1439).

You asked the Plan to pre-approve Injectafer. You say that the requested drug is a medical necessity for the enrollee as the enrollee has trialed oral iron. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.

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 Injectafer. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drugs Ferrlecit, Infed, or Venofer before they will approve the requested drug, Injectafer. Based on the medical records provided, the enrollee has not tried and failed the required drugs. There is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Injectafer (J1439).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the retainer crowns (D6740 x 2), pontic (D6245), pulpal debridement (D3221), take home drugs (D9630), adjunctive pre-diagnostic test (D0431), unspecified periodontal service (D4999 x 2), fluoride varnish (D1206), oral hygiene instructions (D1330), and 2D oral or facial photographic images (D0350 x 4) provided on June 25, 2020.  You asked the Plan to pay for the retainer crowns, pontic, pulpal debridement, take home drugs, adjunctive pre-diagnostic testing, unspecified periodontal services, fluoride varnish, oral hygiene instructions, and 2D photographic images. You say that you were given this provider's name as an in network dentist. You say that you now have a bill for $3,000. The Plan denied your request. The Plan says the dental services you received are not listed as covered services.  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 retainer crowns, pontic, pulpal debridement, take home drugs, adjunctive pre-diagnostic testing, unspecified periodontal services, fluoride varnish, oral hygiene instructions, and 2D photographic images are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retainer crowns (D6740 x 2), pontic (D6245), pulpal debridement (D3221), take home drugs (D9630), adjunctive pre-diagnostic test (D0431), unspecified periodontal service (D4999 x 2), fluoride varnish (D1206), oral hygiene instructions (D1330), and 2D oral or facial photographic images (D0350 x 4) provided on June 25, 2020.
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 you are requesting these to be covered due to their high cost and they are medically necessary. Without the stockings, walking is difficult. The Plan denied your request. The Plan says these dressings are non-covered under the surgical dressing 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.

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 covered.

The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. 

We looked at the file and Medicare rules. The requested power seat elevation system is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast cryoablation (0581T).

You asked the Plan to pre-approve breast cryoablation. You say that you believe cryoablation is in the best interest of the enrollee with multiple comorbidities that place her at high risk for breast surgery which would require general anesthesia. The Plan denied your request. The Plan says breast cryoablation has not been proven as an effective treatment of breast cancer.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of breast cryoablation have not been met. Therefore, we decided that the Plan does not have to pre-approve breast cryoablation (0581T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a tennis club membership for 2021.

You asked the Plan to reimburse you for a tennis club membership. You say that you have been unable to go to your normal health club but in order to help with your back you needed to exercise so you went to a different place. The Plan denied your request. The Plan says a tennis club is not a qualified health club under your Wellness Allowance benefit.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

The Plan's rules for coverage of gym benefits have not been met because a tennis club is not a qualified health club or fitness facility under the Plan's Wellness Allowance benefit. Therefore, we decided that the Plan does not have to reimburse you for a tennis club membership for 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214) provided on August 2, 2021.  You asked the Plan to pay for office visit. You say that the enrollee sees this provider for osteopathic manipulation and this code is payable. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code was billed on the same date as osteopathic manipulation code 98928 so is not generally payable.  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 99214 is office or other outpatient visit for the evaluation and management of an established patient, 30-39 minutes.  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 office visit. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found an evaluation and management service performed on the same day as osteopathic manipulative treatment service does not support a significant, separately identifiable service above and beyond the usual pre-/post- service work associated with the enrollee's condition.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic manipulative treatment to 1 or more regions other than spine services and the application of mechanical traction to 1 or more areas received on August 4, 2021, August 18, 2021, August 23, 2021, and August 30, 2021.  You asked the Plan to pay for the chiropractic manipulative treatment to 1 or more regions other than spine services and the application of mechanical traction to 1 or more areas. You say that going to the chiropractor and physical therapist has provided you with extreme pain relief. The Plan denied your request. The Plan says the services received are not a covered benefit.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.      The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment to 1 or more regions other than spine services and the application of mechanical traction to 1 or more areas received on August 4, 2021, August 18, 2021, August 23, 2021, and August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant (D4211) provided September 2, 2021.  You asked the Plan to pay for the gingivectomy or gingivoplasty. You say that this service was necessary because you have a history of periodontal maintenance. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant (D4211) provided September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for ophthalmological services, medical examination provided on August 3, 2020.  You asked the Plan to pay for ophthalmological services, medical examination. The Plan denied your request. The Plan says the claim was filed past the allowed 12-month timeframe. Therefore, the claim was untimely.  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 ophthalmological services, medical examination was not filed until August 12, 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 ophthalmological services, medical examination provided on August 3, 2020.