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

We decided that the Plan does not have to pre-approve therapeutic lumbar facet injections.

You asked the Plan to pre-approve diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (66493x2) and injection(s), second level (66494x2). You say that previous facet injections have been very beneficial. The Plan denied your request. The Plan says there is no documentation as to why the enrollee is not a candidate for radiofrequency ablation.

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 diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (66493x2) and injection(s), second level (66494x2). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has previously been treated with therapeutic facet injections under the LCD criteria. There is no documentation provided as to why the enrollee is not a candidate for radiofrequency ablation such as established spinal pseudarthrosis, or implanted electrical device as indicated in the current LCD, L38765. The review has determined that the facet joint injections are not medically reasonable or necessary and the criteria has not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (66493x2) and injection(s), second level (66494x2) have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic lumbar facet injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint radiofrequency ablations (RFAs).

You asked the Plan to pre-approve RFAs. You say that you need this service so you will not have back pain anymore. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you have not had at least 2 diagnostic medial branch blocks and you have other non-facet pathologies that could explain the source of your pain.

The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered under certain circumstances, including that there is no non-facet pathology that could explain the source of the patient's pain. 

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 RFAs. Our reviewer says that you do not meet the Medicare criteria for this facet joint intervention procedure. Our physician reviewer found you previously underwent medial branch blocks on the left and right which gave you 80% pain relief. Also of concern is a sacral insufficiency fracture as well as severe levosclerosis. You have 2 other pain generators; therefore, this request is not medically reasonable or 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 RFAs have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint radiofrequency ablations (RFAs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stairway elevator.

You asked the Plan to pre-approve a stairway elevator. You say that carrying the enrollee up and down the stairs for a bath is not ideal. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.

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 stairway elevator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on May 7, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on April 26, 2021 and your problem focused limited oral evaluation
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound compression strapping procedures you had at an outpatient hospital facility from April 1, 2021, to April 29, 2021.

You asked the Plan to waive the copayments for the compression strapping procedures. You say that you have never had to pay for this procedure in the past. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for the procedure ($135.83) is less than your copayment obligation, you are responsible for the full allowed 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 $250 copayment for procedures at an outpatient hospital.

You have been asked to pay a $250 copayment for the compression strapping procedures. The compression strapping procedures fall within the procedures at an outpatient hospital 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 copayments for the wound compression strapping procedures you had at an outpatient hospital facility from April 1, 2021, to April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services to be provided by an out-of-network (OON) provider at the in-network benefit level.

You asked the Plan to pre-approve OON services to be provided at the in-network benefit level. You say that you would like to receive infectious disease services from an out-of-network provider at the in-network benefit level. The Plan denied your request. The Plan says the requested services can be provided by a network provider.

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. We note that if you would like to receive services from this OON provider, you may do so; however, the cost share requirement would be higher for this provider than an in-network provider.

Therefore, we decided that the Plan does not have to pre-approve services to be provided by an out-of-network (OON) provider at the in-network benefit level.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on April 9, 2021.

You asked the Plan to pay for the self-administered drugs. You say that the self-administered drugs should be covered. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on April 9, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from January 16, 2021, to January 31, 2021.

You asked the Plan to pay for the home health services. You say that the hospital suggested that you go to a rehabilitation facility, but your family did not want that which is why you had home care. The Plan denied your request. The Plan says the home health services rendered during this time are considered to be custodial care. The Plan also says that custodial care services are not covered.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the home health services provided from January 16, 2021, to January 31, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health care provided on February 11, 2021.
You asked the Plan to waive the copayment for outpatient mental health care. You say that you disagree with the charges and should not owe anything. 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 $20 copayment for outpatient mental health care. You have been asked to pay a $20 copayment for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health 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 outpatient mental health care provided on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702).

You asked the Plan to pre-approve a MyoPro Motion G orthosis. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is experimental/investigational.

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 a MyoPro Motion G orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the medical records indicate that the enrollee has a residual partial paralysis of the left upper extremity having had an anterior cerebral artery territory ischemic stroke in April 2015. No medical records from the ordering physician were provided sufficient to establish the medical necessity and reasonableness, as defined in the Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 

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 MyoPro Motion G orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G orthosis (L8702).
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 inpatient rehabilitation would best meet the enrollee's needs. The Plan denied your request. The Plan says the enrollee can be treated 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 enrollee does not require treatment by multiple therapies and an intensive rehabilitation therapy program.
While the documentation does support a need for physical or occupational therapy, there is no documented need for a intensive, multi-disciplinary 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided May 24, 2021.
You asked the Plan to pay for the limited oral exam. You say that you were in pain and the appointment was an emergency. The Plan denied your request. The Plan says you have exceeded frequency limits for this service therefore it is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited oral exam once per plan year. We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on January 25, 2021. Based on this information, we determined that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided May 24, 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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary.
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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program.
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 an EZ Lite Cruiser Deluxe Slim SX12 foldable power wheelchair.
You asked the Plan to pre-approve a foldable power wheelchair. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The website of the manufacturer of the item at issue in this appeal states that the item 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 an EZ Lite Cruiser Deluxe Slim SX12 foldable power wheelchair
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on June 30, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you should only owe a $5 copayment. 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 $20 copayment for physician/practitioner services. You have been asked to pay a $20 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the canal preparation (D3950) or pay more for the
endodontic therapy (D3320) provided on February 24, 2021.
You asked the Plan to pay for the canal preparation and to pay more for the endodontic therapy. You say that
you went to your dentist for root canal procedures, but your dentist used codes that were denied. You also say
that your plan covers root canals. The Plan denied your request. The Plan says the canal preparation is not
covered by the Plan. The Plan also says that you are responsible for the coinsurance amount for the endodontic
therapy.
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 canal preparation (D3950) is not
among those covered under this benefit. The contract states that you are responsible for a 70% coinsurance for
root canals. Therefore, we decided that the Plan does not have to pay for the canal preparation (D3950) or pay
more for the endodontic therapy (D3320) provided on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for consultation-diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) received on April 12, 2021, and biopsy of oral tissue - soft (D7286) received on April 22, 2021.

You asked the Plan to pay for the dental consultation and oral biopsy. You say that you have had several issues and would like the services covered. The Plan denied your request. The Plan says these services are 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 consultation-diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) received on April 12, 2021, and biopsy of oral tissue - soft (D7286) received on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two intraoral periapical x-rays (D0707 x2) provided on May 17, 2021.

You asked the Plan to pay for the intraoral periapical x-rays. You say that when you scheduled this appointment you requested a cleaning and did not know there might be additional charges. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 pay for the two intraoral periapical x-rays (D0707 x2) provided on May 17, 2021.