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

We decided that the Plan does not have to pre-approve peripheral nerve stimulation therapy (64555, 95972, 
L8680).

You asked the Plan to pre-approve peripheral nerve stimulation therapy. You say that the service at issue is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met.

The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral 
nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say 
that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist. 

We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an 
implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes 
being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as 
electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered 
through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this 
peripheral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to preapprove peripheral nerve stimulation therapy (64555, 95972, L8680).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that this is not a new order for Prolia, the patient has been on Prolia previously. You also say that the last dose of Prolia was given on September 17, 2021, and their next dose is due March 17, 2022. The Plan denied your request. The Plan says the Medicare criteria have not been met for Prolia to be 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 Prolia (J0897).
Benefits for Prolia 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve a power seat elevation system.. You say that you need this item. The Plan denied your request. The Plan says this item does not primarily service a medical purpose.
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 power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical access to an implant body (D6011).
You asked the Plan to pre-approve the surgical access to an implant body. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.
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 surgical access to an implant body (D6011).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiindra drops.
You asked the Plan to pre-approve Xiindra drops. You say that the enrollee has a long diagnosis with dry eye syndrome. The Plan denied your request. The Plan says the requested drug is not a covered 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 Xiindra drops.
Benefits for Xiindra drops 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: 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 necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 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 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 this 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the requested viscosupplement device.
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 Synvisc. Our reviewer says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative, Monovisc and Orthovisc. Our reviewer also found that the record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one alternative. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) abdomen (74183) to 
be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the MRI. You say that you went to the network provider and after waiting 
for an hour you were told the MRI machine is not working. You were referred to an imaging at another office, 
but you do not want to drive that far. 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. Nonemergent services with non-contracted providers require prior authorization before services being rendered.

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
magnetic resonance imaging (MRI) abdomen (74183) 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 pay for the home health services provided from January 20, 2021, 
through January 29, 2021.

You asked the Plan to pay for the home health services. You say that these services were approved and should 
be paid. The Plan denied your request. The Plan says there is no approval on file for these services. In addition, 
the claim was not billed with the required Q-code.

The Plan must follow Medicare rules. Medicare rules say that home health agencies must report the location in 
which services are rendered by reporting a line item with one of three q-codes on the same date of service as 
the first visit of the episode of care.

The file shows that no Q-code was reported on this claim was required. Therefore, we decided that the Plan
does not have to pay for the home health services provided from January 20, 2021, through January 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), Segmental pneumatic trunk (E0656), and Segmental pneumatic appliance for use with pneumatic compressor (E0667).

You asked the Plan to pre-approve a pneumatic compression device and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the beneficiary does not have lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), Segmental pneumatic trunk (E0656), and Segmental pneumatic appliance for use with pneumatic compressor (E0667).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 14, 2021.

You asked the Plan to waive the copayment for an ultrasound. You say that you were told that you would only owe a $25 copayment and disagree with the 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 $100 copayment for ultrasounds. 

You have been asked to pay a $100 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 August 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Euflexxa.
You asked the Plan to pre-approve Euflexxa. You say that you are seeking treatment with viscosupplementation. The Plan denied your request.
The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Synvisc, Duroland, and Gelsyn-3 before it will approve Euflexxa.
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 Euflexxa. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Euflexxa. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Synvisc, Durolane, and Gelsyn-3. The record does not show that these drugs would likely be less effective and/or 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intraosseous radiofrequency ablation of the 
basivertebral nerve (22899).

You asked the Plan to pre-approve the ablation procedure. You say that the procedure is medically necessary.
The Plan denied your request. The Plan says this procedure is experimental and non-covered.

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 ablation procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered investigational at this time. More research is needed to 
show safety and efficacy of the requested procedure.

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 ablation procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve intraosseous radiofrequency ablation of the basivertebral nerve (22899).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for the Epifix application and an office
visit provided on July 8, 2020.
You asked the Plan to waive these services. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based on the services provided and the Plan
contract agreement. Maximus partially overturned the Plans denial. Maximus instructed the Plan to hold you
harmless for the Epifix charge but that the physician cost share was correct. The Plan requested a reopen and
stated that the Maximus decision is the same as the Plan decision. The Plan provided documentation to show
you are not being charged for the Epifix codes and you are only charged $7.88 for the physician visit.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay 10% coinsurance for
physician visits.
You have been asked to pay the correct amount based on your contract with the Plan. You are not being
charged for anything other than the physician visit. 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 cost share
charged for the physician visit provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225), surgical placement 
of implant body: endosteal implant (D6010), and surgical access to an implant body (D6011).

You asked the Plan to pre-approve the maxillary partial denture, endosteal implant, and surgical access to an 
implant body. You say that all of your upper teeth have fallen out and eating has become a problem. You also 
say that you need the dentures to be able to eat. The Plan denied your request. The Plan says these services are 
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.

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 
maxillary partial denture (D5225), surgical placement of implant body: endosteal implant (D6010), and 
surgical access to an implant body (D6011).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on August 25, 2021.

You asked the Plan to pay for the eye refraction. You say that you would like reconsideration because this 
service has always been covered in the past. The Plan denied your request. The Plan says the services received 
were not for a routine eye exam but disordered of optic disc.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided as part of a routine eye exam.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eye refraction have not been met. Specifically, the record indicates that the refraction was not 
provided as part of a routine eye exam. The record shows that you received a medical eye exam. Therefore, we 
decided that the Plan does not have to pay for the eye refraction (92015) provided on August 25, 2021.
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 necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 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 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 this 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and two or more power seating system motors (E2311) expandable controller, (E2377) harness for upgrade to expandable controller (E2313).
You asked the Plan to pre-approve the upgraded electronics. You say that all of the documentation submitted follows the Medicare guidelines so you believe the denial is in error. The Plan denied your request. The Plan says although there are three approved power options on the approved wheelchair, there is no medical need to control these power options through the joystick.
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 upgraded electronics. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. The documentation shows that the enrollee has 3- to 3/5 bilateral upper limb strength. Upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. The review indicates that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 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 upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and two or more power seating system motors (E2311) expandable controller, (E2377) harness for upgrade to expandable controller (E2313).