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

 We decided that the Plan does not have to issue reimbursement for the office visit (99202) and the chiropractic manipulative treatment (98940) rendered by the out-of-network (OON) provider on July 7, 2021.  You asked the Plan to issue reimbursement for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to issue reimbursement for the office visit (99202) and the chiropractic manipulative treatment (98940) rendered by the out-of-network (OON) provider on July 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eylea.  You asked the Plan to pre-approve Eylea. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug as it is dispensed is not covered under the enrollee's medical benefit.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Eylea.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Freestyle Lite test strips.  You asked the Plan to pre-approve the strips. You say that you are requesting non formulary test strips and expressed preference for Freestyle over One touch systems. The Plan denied your request. The Plan says the request was denied, and alternatives were suggested: OneTouch Ultra test strips, OneTouch Verio test strips (quantity limit of 100 strips per 25 days).  The Plan must follow Medicare rules. Review of the file shows that there was no clinical reason was provided regarding why plan's preferred diabetic testing supplies cannot be used. Based on this information, we decided that Medicare rules for coverage of the strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (CPT code 20939), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.  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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate is experimental. More research is needed to show safety and efficacy of bone marrow aspirate as a bone graft material.   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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (CPT code 20939), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214) provided July 29, 2021.  You asked the Plan to pay for the office visit. You say that this service should be covered. The Plan denied your request. The Plan says the only chiropractic service Medicare covers is manual manipulation of the spine.  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.   We looked at the file and Medicare rules. The code billed is not for manual manipulation of the spine. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided July 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient physical therapy (PT) provided from August 3,
2021, to August 31, 2021, by an OON provider.

You asked the Plan to pay for the outpatient PT. You say that the services were medically necessary. The Plan
denied your request. The Plan says prior authorization was not obtained before the services were 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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service
at issue. We found no exception that would require the Plan to pay for these items/services. The file shows that
you were no longer in a skilled nursing facility during the dates of service in this case. Therefore, we decided
that the Plan does not have to pay for the outpatient physical therapy (PT) provided from August 3, 2021, to
August 31, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (PWC) and attachments for the enrollee.

You asked the Plan to pre-approve a PWC and attachments. You say that this is necessary for the enrollee. The Plan denied your request. The Plan says the enrollee's PWC has not exceeded the 5-year useful lifetime.

The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no case can be less than five years. The enrollee received a power wheelchair three years ago, which is not more than the five year reasonable useful lifetime requirement. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (PWC) and attachments for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve greater than 12 tubes per month of catheter lubricant
(A4402) and non-sterile gloves (A4927).

You asked the Plan to pre-approve a greater supply of catheter lubricant and a supply of non-sterile gloves.
You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says
12 tubes per month of catheter lubricant is sufficient for your needs. The Plan also says that non-sterile gloves
are not a covered benefit.

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 durable medical equipment must fulfill the criteria listed 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 a greater supply of catheter lubricant
and a supply of non-sterile gloves. Our reviewer says that a greater supply of catheter lubricant is not
considered medically reasonable and necessary in this case. Our physician reviewer found that the Plan-approved
12 tubes of catheter lubricant per month is adequate to meet the enrollee's need based upon a
frequency of clean intermittent self-catheterization of 2 to 5 times daily.

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 greater supply of catheter lubricant have not been met. Non-sterile gloves are
not a covered benefit because the requested items cannot withstand repeated use. Therefore, we decided that the
Plan does not have to pre-approve greater than 12 tubes per month of catheter lubricant (A4402) and non-sterile
gloves (A4927).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Xiidra.

You asked the Plan to pre-approve Xiidra. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Xiidra.

Benefits for Xiidra 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213 and D5214), to be provided by a participating provider.

You asked the Plan to pre-approve a maxillary partial denture. You say that you would like the Plan to approve and pay for this. The Plan denied your request. The Plan says the requested dental services are not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213 and D5214), to be provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nuedexta 20-10mg capsules.

You asked the Plan to pre-approve Nuedexta. You say that Nuedexta is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical 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 Nuedexta 20-10mg capsules.

Benefits for Nuedexta 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).

You asked the Plan to pre-approve Durolane. You say that Durolane injections are medically necessary. The Plan denied your request. The Plan says a trial of Euflexxa is required before alternatives like Durolane can be considered.

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 Durolane. Our reviewer says that Durolane is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred drug, or any reason the plan preferred drug would be unsafe or ineffective 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and re-cement crown (D2920) provided on May 3, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and re-cement crown. You say that this was an emergency situation because your crown had fallen off and you needed it fixed because you could not eat. You also say that no in-network dentist could get you an appointment soon enough. The Plan denied your request. The Plan says you received these services from an OON provider. The Plan also says that non-emergency services rendered by an OON provider are not available with 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and re-cement crown (D2920) provided on May 3, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve debridements (11042 and 11043) and home visits (99343) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the debridements and home visits. You say that you believe the wound care would be better provided by the requested OON provider. The Plan denied your request. The Plan says the requested physician is not an in-network physician with your plan. The Plan also says that you were redirected to an in-network wound care service and have started receiving care from them.  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 debridements (11042 and 11043) and home visits (99343) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).  You asked the Plan to pre-approve the additional non-emergency taxi transportation. You say that the enrollee requires transportation to his dialysis treatments. The Plan denied your request. The Plan says the enrollee's transportation benefit has been exhausted.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 one-way trips per year.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a crown (D2751) to be provided by a participating provider.  You asked the Plan to pay for a crown. You say that you would like the Plan to approve these services. The Plan denied your request. The Plan says the x-rays that were provided to show medically necessary were not usable.  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.   We looked at the file and Medicare rules. Based on this information, we decided that due to the x-rays being unusable, these services have been correctly denied. Therefore, we decided that the Plan does not have to pay for a crown (D2751) to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says there are network providers available.  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 a continuous glucose monitor (K0553, K0554) 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 pre-approve bronchial thermoplasty coded as 31660, 31661.  You asked the Plan to pre-approve bronchial thermoplasty. You say that please be aware that Medicare covers this procedure. The Plan denied your request. The Plan says bronchial thermoplasty is not covered as a treatment for any condition, including but not limited to asthma. The benefits and safety of bronchial thermoplasty have not been firmly established in patients with severe asthma.  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 bronchial thermoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve bronchial thermoplasty coded as 31660, 31661.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Percutaneous Image-Guided Lumbar Decompression procedure (0275T).  You asked the Plan to pre-approve the Percutaneous Image-Guided Lumbar Decompression procedure. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.  The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar Decompression is only supported when you are part of an approved clinical trial.  We looked at the file and Medicare rules. The documentation does not show that the enrollee is enrolled in an approved clinical trial. Based on this information, we decided that Medicare rules for coverage of the Percutaneous Image-Guided Lumbar Decompression procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Percutaneous Image-Guided Lumbar Decompression procedure (0275T).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0482) provided on March 4, 2021.  You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure (C9752, C9753, 22899).  You asked the Plan to pre-approve the Intracept 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 Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is still considered experimental. More research is needed to show safety and efficacy.  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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (C9752, C9753, 22899).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that you have many medical conditions that makes it difficult to shower without support. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.