Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy re-evaluation rendered on December 9, 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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 physical therapy re-evaluation rendered on December 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ECG provided on January 26, 2021.
You asked the Plan to waive the copayment for the ECG. You say that this was a pre-op screening for a hip replacement. You say that the coverage book says an EKG is a $0 copayment and you are appealing the charge. The Plan denied your request. The Plan says the copayment 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 $105 copayment for diagnostic procedures and tests performed at an in-network outpatient hospital.
You have been asked to pay $53.17, which is less than the standard $105 copayment for the ECG. The ECG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ECG is considered a diagnostic service. 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 ECG provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray image (D0230) provided on February 10, 2021.

You asked the Plan to pay for the second intraoral x-ray. You say that your dentist found the second image necessary to evaluate a possible problem with another tooth. It was not a second set of x-rays, and should be covered. The Plan denied your request. The Plan says the Plan will cover one intraoral x-ray per calendar year. The Plan has already issued reimbursement for the initial intraoral x-ray (D0220) provided on the same date of service. The second x-ray image exceeds your frequency benefit for the plan year, and payment cannot be made.

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 may cover one intraoral x-ray procedure code per calendar year. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the intraoral x-ray is requested in a frequency that is not covered under this benefit. Intraoral periapical x-rays are billed per image. Documentation shows that the Plan has paid for D0220 (intraoral periapical x-ray, first image) on the same date of service. You were also provided with D0230 (intraoral periapical x-ray, each additional image). These are two separate procedure codes. The Plan has paid for one as stated in the contract. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray image (D0230) provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided on January 26, 2021 and February 2, 2021.

You asked the Plan to waive the coinsurance for the Part B injections. You say that you would like the coinsurance reduced or waived because you are trying to reduce your financial burden. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs.

You have been asked to pay $95.06 which is 20% of the allowed amount for the Part B injections on each date of service. The allowed amount is $475.32. ($475.32 x 20% = $95.06). ($95.06 + $95.06 = $190.12). The Part B injections fall within the "Medicare Part B prescription drugs" 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 the Part B injections provided on January 26, 2021 and February 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the paring of a hyperkeratotic lesion and the nail debridement provided on January 5, 2021.

You asked the Plan to waive the deductible for the pairing of the hyperkeratotic lesion and the nail debridement. You say that you do not believe the podiatry services should apply to the deductible. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible that applies towards podiatry services.

The podiatry services you asked the Plan to waive the deductible for falls within the "Podiatry services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards podiatry services.

This cost sharing is a contractual obligation that had not been met at the time the pairing of the hyperkeratotic lesion and the nail debridement were received on January 5, 2021. Therefore, we decided that the Plan does not have to waive the deductible for paring of the hyperkeratotic lesion and the nail debridement provided on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment/implant supported crown (D6058).

You asked the Plan to pre-approve the abutment/implant supported crown. You say that this crown is necessary to save the dental work you already have done and improve your ability to chew food. The Plan denied your request. The Plan says this type of crown is not covered by the supplemental dental 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 pre-approve an abutment/implant supported crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided January
26, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you were unaware the service was not covered
and would like the Plan to cover the cost. The Plan denied your request. The Plan says a panoramic x-ray as
previously covered and therefore frequency limits have been met and the x-ray at issue is 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. The Plan covers the panoramic
x-ray when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. The Plan provided documentation showing that a panoramic x-ray
was previously covered on June 25, 2019. Based on this information, we decided that the Plan's rules for
coverage of the panoramic x-ray have not been met. Therefore, we decided that the Plan does not have to pay
for the panoramic radiographic image (D0330) provided January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the recliner chair and the seat lift mechanism (E0627) provided on August 20, 2020.

You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of a lift chair.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. Additionally, the rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical purpose.

We looked at this case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Specifically, the documentation provided indicates that your physician submitted a prescription in support of a lift chair after the item was received. The document indicated that you have a history of bilateral arthritis of the hip and recently underwent a hip arthroplasty surgery. However, in order to meet Medicare criteria for coverage of a seat lift mechanism, all criteria must be met. Documentation confirming that you have severe arthritis of the hip must be provided, you must be completely unable to stand up from a regular armchair or any chair in the home, and once standing you must have the ability to walk. There were no medical records provided to determine if all coverage criteria had been met for reimbursement of this item. Additionally, a recliner chair is not durable medical equipment that is mainly used to serve a medical purpose. Therefore, we decided that the Plan does not have to issue reimbursement for the recliner chair and the seat lift mechanism (E0627) provided on August 20, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 61 visits for dialysis services with an out of network provider.

You asked the Plan to pre-approve 61 dialysis visits with an out of network provider. You say that you have been treating with this facility since 2016. The Plan denied your request. The Plan says they will approve 24 dialysis visits to allow you to safely transition to an in-network center.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the remaining 61 visits for dialysis services with an out of network 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 5, 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 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the extended pharmacogenomics (PGx) panel provided on July 14, 2020.

You asked the Plan to pay for the PGx panel. You say that this is medically necessary testing. The Plan denied your request. The Plan says since this is a panel of tests, it must be billed using one single code.

The Plan must follow Medicare rules. Medicare rules say that PGx testing is only covered when a medication is being considered for use, and it is reasonable based on FDA or CPIC recommendations for that particular drug.

In this case, there is no evidence that the enrollee is taking any prescribed medications or that any new prescribed drugs are being considered. As such, it cannot be determined that any gene-drug interaction is suspected for which this PGx testing would aid in therapeutic decision-making. The criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the extended pharmacogenomics (PGx) panel provided on July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided December 3, 2020.
You asked the Plan to pay for the panoramic x-ray. You say that the dental office said the service was covered and you cannot afford the cost. 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 for the panoramic radiographic image (D0330) provided December 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient hospital care provided after an elective left knee arthroplasty.

You asked the Plan to provide coverage for acute inpatient hospital care. The Plan denied your request. The Plan says the enrollee's care can be provided without an inpatient stay after the surgical procedure.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case.

Our physician reviewer found that the records provided do not indicate the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. If necessary, the initial day should be spent in observation until it is clearly expected that a second midnight would be required, at which time the physician may order an inpatient admission. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to provide coverage for acute inpatient hospital care provided after an elective left knee arthroplasty.
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 September 15, 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 September 15, 2020.