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

We decided that the Plan does not have to pay for the laboratory work provided on February 3, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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 laboratory work provided on February 3, 2021 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic massage services provided on December 15,
2020, billed with one unit of code 97124.

You asked the Plan to pay for the therapeutic massage. You say that this is separately payable in addition to
97150 since the -59 modifier was used. The Plan denied your request. The Plan says it was determined that the
therapy note does not support the 15 minutes of massage therapy.

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 97124 is Therapeutic procedure, 1 or more areas, each 15
minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion).

We find that CPT code 97124 is not supported in the medical record. Specifically, although the therapy note
does document one unit of 97124, the timed codes billed for this date of service exceed the 60 minutes noted as the length of the visit. As the note does not fully break down the number of minutes spent on massage therapy, it cannot be determined whether sufficient time was spent on this service to warrant payment. Based on this information, we decided that Medicare rules for coverage of the therapeutic massage have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic massage services provided on December 15, 2020, billed with one unit of code 97124.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency department (ED) evaluation provided on January 2, 2021.
You asked the Plan to pay for the ED evaluation. You say that this patient was seen to evaluate a potentially emergent medical condition. The diagnosis codes used were valid at the date of service and appropriate. The Plan denied your request. The Plan says that payment is not allowed for this service because it is not appropriate for the diagnosis billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide any justification to support its denial rationale that the reported diagnosis code, R51.9 (Headache, unspecified) is not appropriate. This diagnosis code was active for the date of service in question. There are no citations provided which would indicate that this diagnosis is not appropriate for use with an ED visit. The ED note documents the presence of this diagnosis. We find that no valid denial rationale was given to justify non-payment of this claim. Therefore, we decided that the Plan has to pay for the emergency department (ED) evaluation provided on January 2, 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: 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 October 28, 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 October 28, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 21, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on December 17, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and electrical stimulation provided on January 13, 2021.
You asked the Plan to pay for the office visit and electrical stimulation. You say that this was your first visit and it seems reasonable to cover the initial visit. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit and electrical stimulation provided on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next test strips.

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 not covered.

The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred durable medical equipment suppliers. 

We looked at the file and Medicare rules. The requested Contour Next Test Strips are not the preferred provider with the Plan. The Plan provides diabetic testing strips through the preferred providers. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for somatosensory testing (95938 and 95927) provided on July 7, 2020.
You asked the Plan to pay for the somatosensory testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is included in payment to the facility and not separately reimbursable for this provider in this place of service.
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 95938 and 95927 is not supported in the record. Specifically, the record indicates that the member was registered inpatient on the billed date of service. There is a more appropriate place of service code for the services billed. Additionally, payment for these services is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the somatosensory testing have not been met. Therefore, we decided that the Plan does not have to pay for somatosensory testing (95938 and 95927) provided on July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.
You asked the Plan to pre-approve CGM supplies. You say that this is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose testing at least four times per day and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of CGM supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on
October 6, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain
indications.
Review of the file shows that the plan uses Local Coverage Determination (LCD) L36523 to support their
denial. However, LCD L36523 is not valid for the provider's billing state of Arkansas. Therefore, we are unable
to use LCD L36523 to substantiate our decision.
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that
the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the
cardiovascular risk assessment panel provided on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft provided on December 17, 2020.
You asked the Plan to pay for the bone replacement graft. You say that you were advised that this service would be covered at 50%. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft provided on December 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac implantable device.

You asked the Plan to pre-approve the device. You say that you would like the defribrillator taken out due to severe pain. The Plan denied your request. The Plan says the provider does not support this request because of the risks involved.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical documentation does not support that a new or replacement permanent pacemaker with transvenous electrode(s) is medically reasonable and necessary for the enrollee in this case. 

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 a cardiac implantable device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on January 25, 2021.
You asked the Plan to pay for a periodic oral evaluation, and a teeth cleaning. You say that you were not aware you needed to use an in-network provider. The Plan denied your request. The Plan says you are not covered for these services when rendered by an out-of-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, and a teeth cleaning have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers
available to provide these services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), and a teeth cleaning (D1110) provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, spine, lumbosacral (72110) lowlevel
laser treatment, each 15 minutes (S8948) miscellaneous medical supplies and materials (99070) provided
on May 14, 2020, to July 27, 2020, by an OON provider.
You asked the Plan to pay for the chiropractic services. You say that you had therapy on your leg and back.
You did not know it was not in network. 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 rules say that the only chiropractic service Medicare covers
is manual manipulation of the spine to correct a subluxation.
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. The records show that the service at issue is not manual manipulation of the spine. 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 radiologic examination, spine, lumbosacral (72110) low-level laser treatment,
each 15 minutes (S8948) miscellaneous medical supplies and materials (99070) provided on May 14, 2020, to
July 27, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster shingles vaccine provided on January 23, 2021.

You asked the Plan to pay for the Zoster shingles vaccine. You say that the Plan and pharmacy said the vaccine
was covered. The Plan denied your request. The Plan says this vaccine is not covered under your Medicare Part
B drug benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zoster shingles
vaccine. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the Zoster shingles
vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster shingles vaccine provided on
January 23, 2021.

Benefits for the Zoster shingles vaccine may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on July 27, 2020, and August 24, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you were in another country and needed these drugs. The Plan denied your request. The Plan says you received these medications outside of the United States. The Plan also says that Medicare drug plans cannot cover prescription drugs you buy outside the United States.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Services provided outside of the United States are also not covered. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on July 27, 2020, and August 24, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 22, 2020.

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 the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed
above, are not covered.

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on December 14, 2020.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. 

Review of the file shows that the documentation does not support an indication of which the cardiovascular risk assessment would be a covered benefit. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the dental services (D1110, D0274,
D0120) received December 28, 2020, from the out-of-network provider.

You asked the Plan to pay an additional amount for the dental services (D1110, D0274, D0120). You say that
you were not aware that the provider was no longer in the Plan's network. The Plan denied your request. The
Plan says when you receive covered services out-of-network you will be responsible for any coinsurance
amounts, plus 100% of the difference between the Plan's allowed amount and what was billed by the out-of-network
provider.

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 payment is in excess of
that which is covered under this benefit. The Plan agreed to pay 100% of the allowed amount for the dental
services. You are responsible for the difference between the Plan's allowed amount and what was charged by
the out-of-network provider. Therefore, we decided that the Plan does not have to pay an additional amount for
the dental services (D1110, D0274, D0120) received December 28, 2020, from the out-of-network provider.