Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a carotid sinus baroflex activation device (Barostim Neo).

You asked the Plan to pre-approve Barostim Neo procedure. You say that the enrollee is an ideal candidate for Barostim Neo. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 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 Barostim Neo procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Food and Drug Administration has stated that the requested device is device is indicated for the improvement of symptoms of heart failure - quality of life, six-minute hall walk and functional status - for patients who remain symptomatic despite treatment with guideline-directed medical therapy, are New York Heart Association (NYHA) Class III or Class II (who had a recent history of Class III), have a left ventricular ejection fraction less than or equal to 35%, a NT-proBNP less than 1600 pg/ml and excluding patients indicated for Cardiac Resynchronization Therapy (CRT) according to guidelines. In this case, the record indicates that the enrollee has congestive heart failure from ischemic cardiomyopathy. The record indicates that the enrollee has a cardiac resynchronization device in place since August 2021. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Barostim Neo procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a carotid sinus baroflex activation device (Barostim Neo).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for chiropractic services you received on July 15, 2021, and July 22, 2021.  You asked the Plan to waive the copayments for the chiropractic services. You say that you just need corrected Explanations of Benefits (EOBs) so that you can send them to your secondary insurer. The Plan denied your request. The Plan says you were charged these copayments correctly.  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 chiropractic services.   You have been asked to pay a $20 copayment for the chiropractic services. 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 chiropractic services you received on July 15, 2021, and July 22, 2021.   Your complaint about getting corrected EOBs from the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, and preventive procedure provided on June 23, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, and preventive procedure. You say that you were not notified prior to these services that they were not in-network or that you would be responsible for a fee. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that non-emergency services provided 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 periodic oral evaluation, bitewing x-rays, prophylaxis, and preventive procedure provided on June 23, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an oral evaluation with a prosthodontist.  

You asked the Plan to pre-approve an oral evaluation with a prosthodontist. You say that the services are necessary. The Plan denied your request. The Plan says the 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. The Plan says covered services must be performed by a participating general dentist.  

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an oral evaluation with a prosthodontist have not been met. Therefore, we decided that the Plan does not have to pre-approve an oral evaluation with a prosthodontist.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on July 1, 2021 and billed under code 70450.  

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says both the primary code 70496 and the bundled code 70450 have been billed with a modifier of 26. This modifier is not included in the list of Medicare allowed modifiers as stated in the NCCI Policy Manual.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to the omission of the correct modifier. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on July 1, 2021 and billed under code 70450.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).  You asked the Plan to pre-approve the complete dentures. The Plan denied your request. The Plan says these services are 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 complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 36222-59-50 and 36225-59-50 billed for date of service March 14, 2021.  You asked the Plan to pay for procedure codes 36222-59-50 and 36225-59-50. You say that the addition of the -59 modifier on each of these codes justifies separate payment. The Plan denied your request. The Plan says the modifiers billed do no bypass the Correct Coding Initiative edits to allow separate payment.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for procedure codes 36222-59-50 and 36225-59-50 Our reviewer says that these codes should not be separately payable. Our physician reviewer found Current Procedural Terminology (CPT) code 36225 59 LT March 14, 2021, does not for billing or reimbursement consideration. Code 36225 is bundled with CPT 36226LT. A 59 modifier can be appended to unbundle the two services, providing the medical records support the use of the modifier.   The medical record submitted does not include sufficient documentation to validate that 36225 59 LT was a distinct, separate service, therefore this service is not eligible for separate reimbursement.   Our reviewer also found that CPT code 36222 59 also does not meet criteria for billing or reimbursement consideration. CPT 36222 is included in service 36223 50.  A 59 modifier is allowed to unbundle these services, providing the medical records support the use of the modifier.  The medical records submitted does not include sufficient documentation to validate that 36222 59 50 was a distinct/separate service, therefore 36222 59 50 is not eligible for separate reimbursement.     We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure codes 36222-59-50 and 36225-59-50 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 36222-59-50 and 36225-59-50 billed for date of service March 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that the item should be covered. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 the enrollee appears to be stable at this time and requires only additional short-term additional acute care services to further stabilize and wean that can be safely administered at the current facility for the time being. There are no services at the LTACH that the enrollee requires that are not already available at the current facility.    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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network ear, nose, and throat specialist (otolaryngologist).  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 services are available from network providers.  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 a referral to an out-of-network ear, nose, and throat specialist (otolaryngologist).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON office visits. You say that you are able to walk to the requested provider. The Plan denied your request. The Plan says the requested service is available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to hold the member harmless for the Guardant360 testing provided on May 3, 2021.  You asked the Plan to hold the member harmless for the Guardant360 testing. You say that you would like reconsideration because this testing was ordered by an in-network provider and was medically necessary. The Plan denied your request. The Plan says that no prior authorization was received and this testing is experimental.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.  The enrollee was referred for the Guardant360 testing by a contract provider. The file does not show that the plan provided notice that the Guardant360 testing would not be covered. Under Medicare rules, this means the Guardant360 testing is considered approved by the plan. Therefore, we decided that the Plan has to hold the member harmless for the Guardant360 testing provided on May 3, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an endodontic therapy of an anterior tooth (D3310), endodontic therapy of a premolar tooth (D3320), and endodontic therapy of a molar tooth (D3330).  You asked the Plan to pre-approve the endodontic therapies. You say that this treatment has been determined to be medically necessary for you. 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 an endodontic therapy of an anterior tooth (D3310), endodontic therapy of a premolar tooth (D3320), and endodontic therapy of a molar tooth (D3330).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the MyoPro powered upper limb (L8702).  

You asked the Plan to pre-approve the MyoPro. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is experimental.  

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 MyoPro. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no detailed medical records provided from the enrollee's treating medical provider or physical or occupational therapist documenting examination of the affected arm and explaining why the requested device is medically necessary and what prior treatments have been tried and failed. Records indicate the enrollee has a right shoulder subluxation which may be a contraindication to use of the requested device. Current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment.  

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 MyoPro have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro powered upper limb (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a labial veneer (D2962) for tooth # 10.

You asked the Plan to pre-approve the dental service. You say that your dentist advised that the covered composite will not stay. You say that a veneer was recommended instead. You also say that the root canals you received in the past have failed and are continuing to get infections. The Plan denied your request. The Plan says labial veneer is not listed as a covered service.

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 labial veneer is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a labial veneer (D2962) for tooth # 10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).  You asked the Plan to pre-approve the partial dentures. The Plan denied your request. The Plan says these services are 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 maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).  

You asked the Plan to pre-approve the partial dentures. You say that you feel that waiting the standard time frame for the dentures may jeopardize your health. The Plan denied your request. The Plan says these services exceed the maximum counts allowed per period.  

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, maxillary partial denture (D5213) and mandibular partial denture (D5214) are each limited to one procedure every five plan years. The record shows that you received a maxillary partial denture (D5213) and a mandibular partial denture (D5214) on October 3, 2018 and your maxillary partial denture (D5213) and mandibular partial denture (D5214) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an interspinous stabilization device.  You asked the Plan to pre-approve the requested device. You say that the enrollee has failed conservative approaches to treatment. The Plan denied your request. The Plan says unproven procedures are not covered by Medicare.  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 requested device. Our physician reviewer found that the requested spacer is indicated to treat neurogenic intermittent claudication secondary to moderate lumbar spinal stenosis. The spacer may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. The Food and Drug Administration states that the requested procedure is contraindicated if a decompression procedure at the index level has been performed. In this case, the records indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has multi-level facet arthropathy and spondylosis and severe central canal stenosis at L4-L5, the level requested for treatment. The elements of the coverage criteria are not satisfied.  Therefore, the requested service cannot be recommended. 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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.