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

We decided that the Plan does not have to pre-approve 4 additional acupuncture visits.

You asked the Plan to pre-approve 4 additional acupuncture visits. You say that this is medically necessary. The Plan denied your request. The Plan says the requested visits cannot be approved until the enrollee has finished her approved treatments.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 

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 4 additional acupuncture visits. Our reviewer says that the requested visits are not medically necessary. Our physician reviewer found the documentation does not show a consistent increase in pain relief or improvement in functioning. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 additional acupuncture visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional acupuncture visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a privacy flap for a power wheelchair.

You asked the Plan to pre-approve the flap. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary and cannot be covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a privacy flap for a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz XR tablet ER 24hr 11mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is not covered under the medical plan.
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 Xeljanz XR tablet ER 24hr 11mg for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (97530, 72040, 72100, 99212, 97530) received from March 17, 2021 to March 31, 2021.
You asked the Plan to pay for chiropractic services. You say that you have coverage but were denied. The Plan denied your request. The Plan says chiropractic services are clearly defined and specifically denied in the Evidence of Coverage as covered only under specific conditions.
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. The services are not covered benefits of Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for chiropractic services (97530, 72040, 72100, 99212, 97530) received from March 17, 2021 to March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compression device to be provided by an 
out-of-network (OON) provider.

You asked the Plan to pre-approve the pneumatic compression device. You say that you would like 
reconsideration because the member's basic pump has failed due to increased edema in upper thigh and 
abdominal area. The Plan denied your request. The Plan says you do not have an urgent or emergent condition 
and this equipment may be provided 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
the pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for a Polysomnography (95811) provided on September 16, 2021.
You asked the Plan to pay for a Polysomnography. The Plan denied your request. The Plan says that Medicare
guidance says the polysomnogram (PSG) requires a valid diagnosis and must meet coverage criteria.
The Plan follows Medicare rules. Medicare rules say that effective for claims with dates of service on and after
March 3, 2009, the Centers for Medicare & Medicaid Services finds that the evidence is sufficient to determine
that the results of the sleep tests identified below can be used by a beneficiary's treating physician to diagnose
OSA, that the use of such sleep testing technologies demonstrates improved health outcomes in Medicare
beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus reasonable and
necessary under section 1862(a)(1)(A) of the Social Security Act.
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 Polysomnography. Our reviewer says that
the Polysomnography was medically necessary. Our physician reviewer found that in this case the records
provided for review had evidence that suggested the presence of obstructive sleep apnea (OSA). The enrollee
had an Epworth Sleepiness Scale (ESS) of 13. The enrollee had snorting/snoring sounds during sleep. The
enrollee had multiple arousals from sleep. The enrollee had also undergone an overnight oximetry study that
returned abnormal (for a high Oxygen Desaturation Index). All of these findings would point towards the
possibility of the enrollee having OSA. In such a setting it can be concluded that sufficient documentation was
provided to meet the requirements of the NCD for the provision of sleep testing.
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 Polysomnography have been met. Therefore, we decided that the Plan has to
pay for a Polysomnography (95811) provided on September 16, 2021.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 4, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you paid the office visit copayment and you should not owe any additional 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for ultrasounds. You have been asked to pay a $50 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the CMT; extraspinal, 1 or more regions (CPT code 98943), electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (CPT code G0283) and application of a modality to 1 or more areas; traction, mechanical (CPT code 97012) provided to the enrollee on September 8, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says this service is not covered when billed by a chiropractor.
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. Neither Original Medicare nor the Health Plan covers 98943, and G0283 when performed by a chiropractor. Furthermore, only manual manipulation of the spine to correct a subluxation is covered. Therefore, we decided that the Plan does not have to pay for the CMT; extraspinal, 1 or more regions (CPT code 98943), electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (CPT code G0283) and application of a modality to 1 or more areas; traction, mechanical (CPT code 97012) provided to the enrollee on September 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a podiatry visit and an x-ray exam on September 13, 2021.
You asked the Plan to waive the copayments for a podiatry visit and an x-ray exam. You say that you thought the services were covered. The Plan denied your request. The Plan says proper copayment amount was 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 $40 copayment for Medicare covered X-rays and a $25 copayment for Medicare covered podiatry visits. You were billed a $31.88 copayment for the x-ray exam which is less then the required $40.00 copayment charge. With the proper billed amount of $25 copayment charge for the podiatry visit. The total amount billed for $56.88 ($31.88 + $25) is the correct amount billed for the copayments.
You have been asked to pay a $25 copayment for a podiatry visit and $31.88, which is less than the $40 copayment for an x-ray. Podiatry visit and x-ray fall within the Podiatry Service and Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit categories. 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 copayments for a podiatry visit and an x-ray exam on September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the automatic blood pressure monitor.

You asked the Plan to pre-approve the automatic blood pressure monitor. You say that you would like
reconsideration because you require the automatic monitor for a more accurate reading. The Plan denied your
request. The Plan says you are not on dialysis which is the sole diagnosis for coverage.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.

The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to pre-approve the automatic blood pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transforaminal epidural injections.

You asked the Plan to pre-approve the transforaminal epidural injections. You say that you would like 
reconsideration because the requested procedure is medically necessary. The Plan denied your request. The 
Plan says the documentation submitted does not show that the frequency limitations will not be exceeded.

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 transforaminal epidural injections. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found no more than two transforaminal injections may be performed at a 
single setting (e.g. single level bilaterally or two levels unilaterally)." In this case, the review has determined 
that the member does not meet the LCD criteria for coverage of both bilateral transforaminal epidural 
injections.

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 transforaminal epidural injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the transforaminal epidural injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2310) for the enrollee.

You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The Plan denied your request. The Plan says upper limb strength and function are adequate for the enrollee to be able to control the power option using its own switch which is included in the allowance of these power options.

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 additional accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the rules say that the power seat elevation feature (E2300) is non-covered because it is not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. 

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 additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2310) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmological medical examination and evaluation to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 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 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 an ophthalmological medical examination and evaluation to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic consultation (D9310) provided by a
participating provider on September 23, 2021.
You asked the Plan to pay for a diagnostic consultation. You say that you would like the Plan to pay for this.
You say that this was medically necessary. The Plan denied your request. The Plan says the dental service that
was provided 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 pay for a
diagnostic consultation (D9310) provided by a participating provider on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse for travel and lodging services provided from April 4, 2021, through June 16, 2021.
You asked the Plan to reimburse for the services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you did not meet the requirements (100 miles from the facility) for travel and lodging. The Plan states that per their policy for travel and lodging related to a transplant, the Health Plan will cover Medicare Advantage members (HMO/PPO/PFFS) for transportation and lodging when receiving covered transplant services at a distant location (further than the normal community
patterns of care). The Plan states normal community patterns of care are defined as being 100 miles or more from the patient's home. The Plan states your primary residence is only sixty (60) miles from the facility where the transplant was performed, and you were fully advised of this prior to services and prior to renting the apartment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. You did not meet the requirements (100 miles from the facility) for travel and lodging. Therefore, we decided that the Plan does not have to reimburse for travel and lodging services provided from April 4, 2021, through June 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for exercise therapy (97110) provided on May 17, 2021.

You asked the Plan to waive the copayment for the exercise therapy. You say that the copayment should be $30 as the provider is in network. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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 $55 copayment for Outpatient rehabilitation services.

You have been asked to pay a $55 copayment for exercise therapy. Exercise therapy falls within the Outpatient rehabilitation 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 exercise therapy (97110) provided on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 4-wheeled power operated vehicle.

You asked the Plan to pre-approve a 4-wheeled power operated vehicle. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for the requested item have not been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file does not show that you have been professionally evaluated for use of the requested item. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 4-wheeled power operated vehicle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain crowns (D2740 x 6), core build up (D2950 x
6), and scaling and root planing (D4341) for all 4 quadrants.

You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied
your request. The Plan says porcelain crowns are not listed as covered services. The Plan says that core build
up are not listed as covered services. The Plan says that scaling and root planing is covered once every 3
calendar years, per quadrant. The Plan also says that the frequency limit has been reached.

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 porcelain crowns and
core build up are not among those covered under this benefit. Additionally, the frequency limit for scaling and
root planing has been reached. The record shows that the Plan paid for scaling and root planing for the upper
right and lower right quadrants performed on June 12, 2020, and the upper left and lower left quadrants
performed on July 18, 2020. Therefore, we decided that the Plan does not have to pre-approve porcelain
crowns (D2740 x 6), core build up (D2950 x 6), and scaling and root planing (D4341) for all 4 quadrants.