Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says the Plan covers 96 one-way trips per calendar year and the 97th trip and beyond is not a covered benefit.
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.
We looked at your request, the records in the case file, and the rules. The file shows that the Plan covers up to 96 one-way routine transportation trips per calendar year. The 97th trip and beyond is not a covered benefit. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), crown (D2740), and core buildup, including any pins when required (D2950), or pay more for the first intraoral periapical x-ray (D0220) provided on June 11, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the problem focused limited oral evaluation, crown, and core buildup, and to pay more for the first intraoral periapical x-ray. You say that you contacted the Plan prior to these services being rendered and were told some of the services would be covered. The Plan denied your request. The Plan says the problem focused limited oral evaluation, crown, and core buildup are not covered expenses under your dental plan. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the problem focused limited oral evaluation (D0140), crown (D2740), and core buildup, including any pins when required (D2950) are not among those covered under this benefit. The contract also says that you are responsible for a 50% coinsurance for intraoral x-rays that are received OON, plus the difference between the billed amount and allowed amount. The Plan also says that during your call with the Plan you were advised that crowns and dentures are not covered benefits, and that fillings are covered at 2 per year. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), crown (D2740), and core buildup, including any pins when required (D2950), or pay more for the first intraoral periapical x-ray (D0220) provided on June 11, 2021 by an out-of-network (OON) provider.
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 a transfer to an IRF is medically necessary. The Plan
denied your request. The Plan says the medical records do not support the need for an intensive rehabilitation
therapy.
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's medical problems are stable.
There are no complex nursing or rehabilitation needs. The enrollee's medical problems are stable. There are no
complex nursing or rehabilitation needs. 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 service
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics - porcelain fused to predominantly base metal (D6241) for teeth 19 and 21 and a pontic - resin with predominantly base metal (D6251) for tooth 20.
You asked the Plan to pre-approve pontics. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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 pre-approve pontics - porcelain fused to predominantly base metal (D6241) for teeth 19 and 21 and a pontic - resin with predominantly base metal (D6251) for tooth 20
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the hospital bed is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that the requested semi-electric hospital bed is not medically necessary. Our physician reviewer found although a fixed position hospital bed appears to be supported, there was insufficient records to support a semi-electric hospital bed. The record does not clearly show a need for frequent or immediate changes in body position. 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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like coverage for an LTACH admission. The Plan denied your request. The Plan says based on Medicare guidelines, the requested LTACH services do not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided indicating medical necessity for admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has age-related
osteoporosis without osteoporotic fracture. The records do not show that she has tried and failed the Plan's
required drugs, oral or intravenous (IV) bisphosphonates and Prolia. The records do not show that the required
drugs would be contraindicated or less effective; therefore, Evenity is not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Evenity
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 enrollee meets all criteria for admission to an IRF. The Plan denied your request. The Plan says the enrollee is stable to discharge to another level of care.
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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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. There is not a reasonable expectation that the 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899 and C9752), for the enrollee.

You asked the Plan to pre-approve the intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental for back pain. More research is needed. 

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 the intracept procedure (CPT code(s): 22899 and C9752), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies, adult disposable diapers, under pads and wound cleanser.

You asked the Plan to pre-approve incontinence supplies. You say that the enrollee has urinary incontinence and needs these supplies. The Plan denied your request. The Plan says these items are hygienic items and is not covered benefits under Medicare.

The Plan covers all items that Medicare covers. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.

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. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, adult disposable diapers, under pads and wound cleanser.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Infuse BMP-2 Allograft (20930).

You asked the Plan to pre-approve the Allograft. You say that the Allograft procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and not 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 Allograft. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found based on the provided documentation and available evidence related to the use of BMP-2 Allograft in the setting of posterolateral lumbar spinal fusion, there is insufficient support made for routine use of this product in this specific surgical clinical situation. 

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 Allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve an Infuse BMP-2 Allograft (20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you have swollen legs. The Plan
denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture (D0364), second stage implant surgery (D6011 x 2), semi-precision attachment (D6192 x 2), and semi-precision abutment (D6191 x 2).
You asked the Plan to pre-approve the dental services. You say that your bottom plate will not stay in due to bone loss. You say that it is embarrassing. You say that you cannot chew food. You say that your gums are raw from trying to eat. You also say that your jaws hurt bad. The Plan denied your request. The Plan says the requested dental services are not listed as 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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture (D0364), second stage implant surgery (D6011 x 2), semi-precision attachment (D6192 x 2), and semi-precision abutment (D6191 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on May 13, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 99203 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 99203 (office visit) and 01480 (anesthesia for open
procedures on the bone of lower leg). Code 99203 is a column II code with a modifier indicator of 1 when
billed with column I code 01480. Code 99203 was not billed with an appropriate modifier to allow for separate
payment. Therefore, we decided that the Plan does not have to pay for the office visit rendered on May 13,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the orthopedic office visit to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve the orthopedic office visit. You say that you do not trust any other provider
and you do not want to see the contracted provider. The Plan denied your request. The Plan says the provider is
out-of-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. The records provided for review do not show that the service at
issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the orthopedic
office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection between the wheelchair controller and two or more power seating system motors (E2311).

You asked the Plan to pre-approve the E2311 electronic connection unit. You say that it is felt that the requested items and accessories should be approved due to medical necessity. The Plan denied your request. The Plan says all of the requested items are approved aside from the E2311 power connection. The enrollee is capable of using the switches for each of the power seating features.

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 E2311 electronic connection unit. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the item coded E2311 is requested to allow control of the power tilt and power elevating leg rest features of the approved power wheelchair. Based on the records provided, there is no clear medical reason why both power options need to be controlled through the same joystick. She does have use of her hands and can operate and control the power options using the switches that are included with these features.

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 E2311 electronic connection unit have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between the wheelchair controller and two or more power seating system motors (E2311).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (CPT code 64624).
You asked the Plan to pre-approve the service. You say that you need this procedure. The Plan denied your request. The Plan says genicular radiofrequency ablation is considered experimental and/or unproven as there is not enough medical proof that shows the safety and/or success of this treatment.
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 genicular nerve ablation remains experimental for knee pain. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (CPT code 64624).