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

We decided that the Plan does not have to pay forthe wrist hand orthoses and lumbar-sacral orthosis provided on August 14, 2020.You asked the Plan to pay forthe wrist hand orthoses (L3916) and lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the information in the enrollee's medical record does not adequately support the medical necessity for the orthoses.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 the wrist hand orthoses (L3916) and lumbar-sacral orthosis (L0650). Our reviewer says that the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back.The documentation in the case file does not support that the requested wrist/hand orthoses were medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the wrists would reasonably be required to adequately assess whether the wrist/hand orthoses were medically reasonable and necessary. The documentation does not support that the wrist/hand orthoses were medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the wrists.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 wrist hand orthoses (L3916) and lumbar-sacral orthosis (L0650) have not been met.Therefore, we decided that the Plan does not have to pay forthe wrist hand orthoses and lumbar-sacral orthosis provided on August 14, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 2, 2020.You asked the Plan to pay forthe nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered.The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decidedthat Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met.Therefore, we decided that the Plan does not have to pay forthe nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on June 26, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that your physician provided medically necessary services in good faith. In consideration for the services rendered, your doctor is seeking reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. 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. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on June 26, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 20, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.

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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. 

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed.

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided October 30, 2020.You asked the Plan to pay forthe periodontal maintenance. You say that the services were medically necessary.The Plan denied your request. The Plan says this service is not covered under your dental benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodontal maintenance (D4910) provided October 30, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing panels provided on July 25, 2020.

You asked the Plan to pay for the drug testing provided. You say that the lab report supports the billed services. The Plan denied your request. The Plan says there is no valid physician order submitted despite requests for this documentation.

The Plan must follow Medicare rules. Medicare rules say that the record must include an order for lab testing provided, which clearly documents the provider's intent that the rendered testing be performed. 

In this case, only the lab report was submitted for review. The Plan made several requests for a copy of the order or medical records to support the intent to order this testing, which was not received. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing panels provided on July 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an inpatient hospital stay provided by a
participating provider on November 30, 2020, to December 9, 2020.

You asked the Plan to waive the co-payment for an inpatient hospital stay. You say that this co-payment is way
too high. You say that you would have to use all of your social security check on this. The Plan denied your
request. The Plan says the correct co-payment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
co-payment per day for days 1-5. There is a $0 co-payment for additional days for inpatient hospital care.

You have been asked to pay a $150 co-payment per day for days 1-5. There is a $0 co-payment for additional
days for an inpatient hospital stay. The total amount you are being asked to pay is $750 ($150 x 5 days = $750).
The correct co-payment has been applied to the inpatient hospital stay that was provided. An inpatient hospital
stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment
for an inpatient hospital stay provided by a participating provider on November 30, 2020, to December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a LifeVest provided on December 22, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for a LifeVest. You say that you would like this claim reprocessed and paid. The
Plan denied your request. The Plan says the member's primary care physician did not refer these services or
obtain 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. 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.
Therefore, we decided that the Plan does not have to pay for a LifeVest provided on December 22, 2020 by an
out of network (OON) provider.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 record does not indicate that the enrollee requires acute care services that she is not currently receiving that would be available at the LTACH facility. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended at this time. 

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: Favorable

We decided that the Plan has to pre-approve Doxorubicin (Q2050).
You asked the Plan to pre-approve Doxorubicin. You say that the use of this treatment is medically necessary. The Plan denied your request. The Plan says that the requested treatment of chordoma with Doxil is not medically reasonable and appropriate in this clinical situation.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Doxorubicin. Our reviewer says that Doxorubicin (Q2050) meets coverage criteria. Our physician reviewer found Doxorubicin is safe, effective and otherwise medically reasonable and necessary for this enrollee. Our reviewer also says that the use of Doxorubicin is supported by clinical research and the approved Medicare compendia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Doxorubicin have been met. Therefore, we decided that the Plan has to pre-approve Doxorubicin (Q2050).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ConfirmMDx testing rendered on December 9, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not medically necessary.The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is covered when specific criteria are met.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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee had elevated prostate specific antigen (PSA). A prostate biopsy was benign on December 9, 2020. The documentation does not support that the enrollee needed repeat biopsy due to persistent or elevated cancer-risk factors. The testing was therefore 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 pay forthe ConfirmMDx testing rendered on December 9, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computerized tomography (CT) scan of the thorax.
You asked the Plan to pre-approve a CT scan of the thorax.. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scan of the thorax. Our reviewer says that the documentation does support that the requested CT scan is medically reasonable or necessary. Our physician reviewer found the enrollee has previously had anaplastic carcinoma of mediastinum treated with chemoradiation, bronchiectasis and chronic obstructive pulmonary disease (COPD). The enrollee also has a history of latent tuberculosis and pulmonary embolus during treatment in 2015 but has not been anticoagulated in 2015. The medical record documentation provided provides sufficient information to establish the medical necessity and reasonableness of the requested service. Therefore, the enrollee meets criteria for the requested services. 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 CT scan of the thorax. have been met. Therefore, we decided that the Plan has to pre-approve a computerized tomography (CT) scan of the thorax.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Foundation F1Heme testing provided on November 23, 2020.

You asked the Plan to pay for genetic testing. You say that this claim was denied in error, as you are the only provider of this service. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.

The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 for date of service November 23, 2020.

We looked at the file and Medicare rules. This testing was not billed with the appropriate codng. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Foundation F1Heme testing provided on November 23, 2020.