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

We decided that the Plan does not have to provide additional reimbursement for the partial upper denture with a flexible base (D5225) provided on January 12, 2021.

You asked the Plan to provide additional reimbursement for the denture. You say that you did not know that your dental allowance changed in 2021 and you cannot afford the extra cost. The Plan denied your request. The Plan says the dental allowance for 2021 is $750 as stated in the contract. You are responsible for any amount for dental services that exceeds this allowance.

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 covers preventative and comprehensive services up to a $750 annual allowance.

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services that exceed the $750 annual dental allowance are not covered under this benefit. Therefore, we decided that the Plan does not have to provide additional reimbursement for the partial upper denture with a flexible base (D5225) provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 17, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided by an out-of-network provider on September 17, 2020.
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 22, 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 22, 2020.
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 July 24, 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 July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator for the enrollee.

You asked the Plan to pre-approve a home ventilator. You say that this is medically necessary. The Plan denied
your request. The Plan says that the medical records do not support Medicare criteria for the requested
ventilator for this patient.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.

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 home ventilator. Our reviewer says
that a home ventilator is not medically reasonable and necessary for the enrollee. The enrollee has chronic
obstructive pulmonary disease with secondary pulmonary hypertension. The requested ventilator would be used
in the AVAPS-AE mode during the night. The submitted medical records do not indicate why a BIPAP
machine with AVAPS technology would not be appropriate for the enrollee. The medical record is insufficient
to determine whether unique characteristics of the enrollee's clinical situation require the use of a ventilator
rather than an appropriate BiPAP device. Our physician reviewer found that the enrollee's condition does not
meet Medicare criteria for a home ventilator.

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 home ventilator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a home ventilator for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says the LTACH services are not medically necessary.

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. LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. There are no required medical services identified that are available at the LTACH, that are not available at the health care setting that was being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 17, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says with
limited exceptions, while you are a member of our plan you may be required to use network providers to get
your medical care and services. The only exceptions are emergencies, or urgently needed services when the
network is not available.

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
physician's 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 physician's services provided on November 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from November 1, 2020 to November 20, 2020.

You asked the Plan to pay for home health services. You say that you would like reconsideration because you were not informed that you were out-of-network with this Plan. The Plan denied your request. The Plan says the claim form does not have the appropriate home health data to process and pay the claim.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was submitted with an invalid type of bill code for home health services. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from November 1, 2020 to November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on January
14, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was applied 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 $35
copayment for each in-person specialist visit.

Review of the file shows that you received specialist services while under outpatient status on January 14,
2021. You have been asked to pay a $35 copayment for these services. These services fall within the in-person
specialist visit 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 copayment for the specialist services
rendered on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the TruBalance Static Seat, power elevating leg rests and electronic connection.

You asked the Plan to pre-approve the wheelchair accessories. You say that you would like reconsideration because the requested accessories are medically necessary. The Plan denied your request. The Plan says the seat lift does not serve a primary medical purpose, the upgraded electronics are not medically necessary, the notes do not show that you have a medical need for power leg lifts and the approved cushion includes all parts needed for it to work properly.

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 wheelchair accessories. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the seat elevator is not considered primarily medical in nature. The power elevating leg rests are not medically necessary as the medical progress note documentation does not indicate the patient has a cast or brace that makes the patient unable to flex 90 degrees at the knee, has significant lower extremity edema, or has a reclining back on a wheelchair. Because these power options are not medically necessary, the electronic connection is also not 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 the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the TruBalance Static Seat, power elevating leg rests and electronic connection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the periodic oral evaluation (D0120), resin-based composite - three surfaces, anterior (D2332), resin-based composite - two surfaces, anterior (D2331), resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335), and resin-based composite - four or more surfaces, posterior (D2394) provided October 23, 2020, and the extraction of erupted teeth or exposed roots (D7140) provided October 27, 2020, by an out-of-network (OON) provider.

You asked the Plan to provide additional payment for the periodic oral exam, resin-based composites and tooth extractions. You say that you had the services pre-approved and were not told that the dentist was OON. The Plan denied your request. The Plan says OON providers are allowed to balance bill you for the difference between their billed amount and the Plan's allowed amount.

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 covers the periodic oral exam, resin based composites and tooth extractions up to the Plan's network rate. 

We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan at the time of the service. 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 provide additional payment for the periodic oral evaluation (D0120), resin-based composite - three surfaces, anterior (D2332), resin-based composite - two surfaces, anterior (D2331), resin-based composite - four or more surfaces or involving incisal angle (anterior) (D2335), and resin-based composite - four or more surfaces, posterior (D2394) provided October 23, 2020, and the extraction of erupted teeth or exposed roots (D7140) provided October 27, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says a provider statement and supporting documentation is needed.

The Plan must follow Medicare rules. Medicare rules say that a continuous glucose monitor is covered under
specific circumstances.

The plan attempted to get medical records but was unsuccessful. There is no evidence that the criteria for the
monitor is met. Based on this information, we decided that Medicare rules for coverage of the monitor have not
been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous
glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 17, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 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 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided by an out-of-network provider on November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the initial periapical x-ray (D0220) and that additional periapical x-rays (D0230 x 3) provided on February 11, 2021.

You asked the Plan to waive the coinsurance for the dental services. You say that you received a bill provider billed you for $200. The Plan denied your request. The Plan says periapical x-rays (single toot x-rays) are listed under Class 2 Basic Services. The Plan also says there is a 20% coinsurance for Class 2 Basic Services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and periapical x-rays are listed as covered, there is a 20% coinsurance for Class 2 Basic Services which includes periapical x-rays.

This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the coinsurance for the initial periapical x-ray (D0220) and that additional periapical x-rays (D0230 x 3) provided on February 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy (PT) and specialist services rendered on April 15, 2020.
You asked the Plan to waive the copayments for these services. You say that you should only have one copayment. The Plan denied your request. The Plan says the copayments were applied 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 $35 copayment per Medicare-covered visit for physical therapy and a $35 copayment per visit to a specialist.
Review of the file shows that you received PT services on April 15, 2020. You have been asked to pay a $35 copayment for these services. These services fall within the physical therapy benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received needle insertion services from a specialist on April 15, 2020. You have been
asked to pay a $35 copayment for these services. These services fall within the specialist visit benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $70. 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 the physical therapy (PT) and specialist services rendered on April 15, 2020.