Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from
January 19, 2021, to May 22, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you used to only be
charged a $25 copayment for the device but now you are also being charged a $25 copayment for the related
supplies and you disagree with the additional charges. The Plan denied your request. The Plan says the claims
were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25
copayment for DME and related supplies.
You have been asked to pay $130.77, which is less than the total copayment amount for DME and related
supplies. DME and related supplies fall within the DME and related supplies benefit category. This means that
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the coinsurance for DME and related supplies provided from January 19, 2021, to May
22, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494).
You asked the Plan to pre-approve facet joint injections. You say that this is medically necessary. The Plan
denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure,
there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of
relief being consistent with the agent used) for a second confirmatory diagnostic facet joint procedure to be
considered medically reasonable and necessary.
We looked at the file and Medicare rules. The records document that the first injections provided only 50%
pain relief. Based on this information, we decided that Medicare rules for coverage of facet joint injections
have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections
(64493, 64494).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute.
You asked the Plan to pre-approve a crutch substitute. You say that you need this before your knee surgery.
The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch
substitutes (E0118).
We looked at the file and Medicare rules. The DME MAC, the contractor responsible for coverage of medical
equipment in the State of Michigan has decided that the crutch substitute coded as E0118 is not medically
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of a crutch
substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve a crutch
substitute.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve echocardiography services.
You asked the Plan to pre-approve echocardiography services. You say that these services are medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that transthoracic echocardiography services are subject to 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 echocardiography services. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found at issue is the medical necessity for performance of a transthoracic echocardiogram (TTE) in an asymptomatic patient with physical exam showing no cardiac abnormalities, with electrocardiogram showing borderline intraventricular conduction delay. Guidelines do not support a need for TTE in this setting. As a
result, at this time TTE would not be considered medically appropriate and necessary in this patient's clinical management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of echocardiography services have not been met. Therefore, we decided that the Plan does not have to pre-approve echocardiography services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure 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 procedure 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 Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to demonstrate the safety and efficacy of the requested procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial plate (CPT code D5211) and three (3) dental extractions (CPT code D7210 X 3) to be provided by an oral surgeon.
You asked the Plan to pre-approve the dental services. You say that you were seen at a dental office and were told to see an oral surgeon for three (3) extractions and a partial plate. The Plan denied your request. The Plan says consults and dental services provided by Oral Surgeons, Periodontists, Endodontists, other dental specialists or non-network General Dentists 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. Services must be performed by a participating general dentist. Therefore, your request to receive dental services by an oral surgeon is not covered. Therefore, we decided that the Plan does not have to pre-approve a partial plate (CPT code D5211) and three (3) dental extractions (CPT code D7210 X 3) to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture Initial 15-minutes (97810) transcutaneous
electrical modulation pain reprocessing (0278T) provided July 12, 2021.
You asked the Plan to pay for the acupuncture services. You say that you have tried other treatments and
nothing else has helped. The Plan denied your request. The Plan says acupuncture is not covered for the
treatment of polyneuropathy.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, electrical sympathetic stimulation therapy devices are
considered to be investigational. Acupuncture is only covered for the treatment of chronic lower back pain.
Therefore, we decided that the Plan does not have to pay for acupuncture Initial 15-minutes (97810)
transcutaneous electrical modulation pain reprocessing (0278T) provided July 12, 2021.
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 criteria for admission to an LTACH are not met. The enrollee is receiving appropriate care in the hospital and there is no advantage in transferring to an LTACH at this time. The enrollee can stay in the hospital until they are safe for transfer or discharge. The Plan denied your request. The Plan says LTACH services are medically necessary for this enrollee, who requires daily physician monitoring and interventions.
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 have a poor prognosis and is not stable for transfer at this time. The remaining acute care services can be safely administered at the current facility until a lower level of care is chosen and appropriate in the short-term. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Transfer to LTACH will be considered not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered soon
when treatment has completed. 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: 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 unstable requiring short-term additional acute care to
stabilize the enrollee 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 and covered at the current
facility. Transfer may be considered when the enrollee is more stable and when treatment has completed.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (gum treatment), 1 to 3 teeth per quadrant, (D4261) for tooth # 29.
You asked the Plan to pre-approve the gum treatment. You say that this service should be covered. You say that your plan covers preventive care. You also say that this service will prevent you from losing your tooth. The Plan denied your request. The Plan says gum treatment 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 gum treatment is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve osseous surgery (gum treatment), 1 to 3 teeth per quadrant, (D4261) for tooth # 29.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 5, 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 28735 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 28735 is arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with osteotomy (eg, flatfoot correction).
We find that CPT code 28735 is not supported in the medical record. Specifically, there is no documentation of transverse, midtarsal or tarsometatarsal arthrodesis, with osteotomy. 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 pay for the surgical services rendered on February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (CPT code(s): 64635 and
64636), for the enrollee.
You asked the Plan to pre-approve the injections. You say that the enrollee has had this procedure done on the
left side and now needs the right side done. The Plan denied your request. The Plan says the Medicare rules
have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Review of the file shows that
the enrollee has already exhausted their two (2) sessions per spinal region within twelve (12) rolling months.
Based on this information, we decided that Medicare rules for coverage of the injections have not been met.
Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (CPT code(s): 64635
and 64636), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says recent articles indicate that this device has a significant adverse outcomes (more than 30% failure rate) and reoperation requirement within the first two years of placement.
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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1851) provided on December 21, 2020.
You asked the Plan to pay for a knee brace. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order or proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success.
Therefore, we decided that the Plan does not have to pay for a knee brace (L1851) provided on December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the shoe inserts (CPT code L3020).
You asked the Plan to pre-approve the shoe inserts. You say that you are requesting review of denial of
services. The Plan denied your request. The Plan says the medical records available for review do not indicate
that you use any type of leg brace and the records indicate you are requesting the shoe inserts related to ankle
pain and injury.
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 the shoe inserts (CPT code L3020)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the facet joint injections (CPT code(s): 64494 and
64493), for the enrollee.
You asked the Plan to pre-approve the facet joint injections. You say that the services are medically necessary
based on low back pain. The Plan denied your request. The Plan says the enrollee had injections on dates of
service March 10, 2021, and November 15, 2021, with 70% relief noted from the later procedure. The Plan
states this supports four (4) diagnostic joint sessions in a rolling twelve (12) month period.
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 facet joint injections. Our physician
reviewer found the LCD requires 80% pain relief from each set of diagnostic MBBs. This was not achieved.
Therefore, the request is deemed 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 the facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve the facet joint injections (CPT code(s): 64494 and 64493), for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that a semi-electric hospital bed is needed due to risk of aspiration pneumonia. The Plan denied your request. The Plan says the requested semi-electric hospital bed is not medically necessary.
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 a semi-electric hospital bed. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee's condition does not require positioning of the body in ways not feasible in an ordinary bed or special attachments that cannot be fixed and used on an ordinary bed. In order to qualify for a semi-electric hospital bed, the enrollee's condition must require frequent change in body position and/or there may be an immediate need for a change in body position and the enrollee can operate the controls and cause the adjustments. The documentation does not indicate that there is a frequent or immediate need for body position changes. 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 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ocular prosthesis (V2624-LT, V2625-LT) provided July
26, 2021.
You asked the Plan to pay for the ocular prosthesis. You say that this service was medically necessary. The
Plan denied your request. The Plan says the claim was not billed with the correct diagnosis code or anatomical
modifiers.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code V2624-LT, & V2625-LT is not supported in the medical record. Specifically, the
procedure codes billed had the LT modifier indicating the procedure was done on the left eye, while the
diagnosis code billed was for the right eye. Based on this information, we decided that Medicare rules for
coverage of the ocular prosthesis have not been met. Therefore, we decided that the Plan does not have to pay
for an ocular prosthesis (V2624-LT, V2625-LT) provided July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve drainage of abscess, cyst, hematoma, vestibule of mouth; complicated (CPT code 40801) and unlisted procedure, dentoalveolar structures (CPT code 41899), for the enrollee.
You asked the Plan to pre-approve the dental services. You say that the enrollee has advanced Alzheimer's and is unable to communicate, cooperate, and is combative at times. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that
are not covered or paid for by Medicare. Extractions that are due to decay or periodontal disease is non-covered per Medicare. Therefore, we decided that the Plan does not have to pre-approve drainage of abscess, cyst, hematoma, vestibule of mouth; complicated (CPT code 40801) and unlisted procedure, dentoalveolar structures (CPT code 41899), for the enrollee.