Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued care with an out-of-network (OON)
hematologist/oncologist.
You asked the Plan to pre-approve continued care with an OON provider. You say that the requested continued
care with the OON hematologist/oncologist is medically necessary. The Plan denied your request. The Plan
says the requested continued care with the OON hematologist/oncologist is not medically necessary.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you
must use contract providers for care.
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 continued care with an OON provider.
Our reviewer says that the requested continued care with the OON hematologist/oncologist is not medically
necessary. Our physician reviewer found the enrollee is diagnosed with stage IV T3N1M0 prostate cancer and
has been seeing the requested OON provider for the last two years, prior to his enrollment with the current
Plan. He may still be receiving Lupron but can be easily transitioned to another provider as given every 3
months. There is nothing unique about this enrollee's condition that would make it medically necessary for him
to continue care with the OON provider. The Plan has shown that they have in-network specialists available
who have the qualifications and expertise necessary to meet the current medical Standards of Care required for
treatment of the enrollee's condition. This enrollee's medical management and/or follow-up care can be safely
transitioned to an in-network specialist.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued care with an OON provider have not been met. Therefore, we decided
that the Plan does not have to pre-approve continued care with an out-of-network (OON)
hematologist/oncologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam (92012) provided December 22, 2020.
You asked the Plan to waive the copayment for the eye exam. You say that this was a routine eye exam and there should be no copayment. The Plan denied your request. The Plan says the exam was properly coded as a medical eye exam and the correct copayment was applied.
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 $50 copayment for Medicare Covered Eye exams. You have been asked to pay a $50 copayment for the eye exam. The eye exam falls within the Medicare covered eye exams 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 an eye exam (92012) provided December 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee is contraindicated to zoledronic acid due to stage III chronic kidney disease. The Plan denied your request. The Plan says the enrollee has not tried an oral bisphosphonate drug and zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our physician reviewer found that the enrollee is noted to have osteoporosis. The health plan requires that other forms of osteoporosis medications be used. While the enrollee has taken two courses of an oral bisphosphonate, there is no evidence that the enrollee has taken zoledronic acid. There is no evidence that the enrollee is allergic to zoledronic acid. While the provider repeatedly states that advanced kidney disease precludes the use of zoledronic acid, laboratory data does not show that the enrollee has advanced kidney disease. There is no documentation as to why zoledronic acid would not be expected to be safe and effective for the enrollee. Therefore, the requested Prolia is not shown to be currently medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
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 August 14, 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 August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services (G0463) provided November 12, 2020.

You asked the Plan to waive the copayment for the outpatient hospital services. You say that the service should be covered in full. The Plan denied your request. The Plan says the correct cost-sharing was applied.

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 $250 copayment for outpatient hospital services. 

You have been asked to pay the Medicare allowable amount of $117.97 for the outpatient hospital services. In this case, the allowable amount is less than the $250 copayment listed in the plan contract. 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 outpatient hospital services (G0463) provided November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office consultation with an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says that there are equally qualified in-network specialists available to you that can provide the services you are requesting.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office consultation to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (90833, 99214) provided January 15, 2019 to February 12, 2019.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was filed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the physician services was not filed until December 24, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for physician services (90833, 99214) provided January 15, 2019 to February 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Perforomist.
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 medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD). Performist (used in combination with the Trelegy Ellipta) is not supported in the Medicare-approved drug compendia for COPD. Concurrent use of one long-acting beta2-agonist with another long-acting beta2-agonist should be avoided due to the risk for toxicity. Perforomist is not safe and effective or reasonable and 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 pre-approve Perforomist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive procedure and to pay more for the extraction provided on January 22, 2021 by an OON provider.

You asked the Plan to pay for the adjunctive procedure or pay more for the extraction. You say that you would like these services to be covered. The Plan denied your request. The Plan says the adjunctive procedure is not a covered expense under your plan. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the 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, unspecified adjunctive procedure is not among those covered under this benefit. The contract also says that you are responsible for the coinsurance plus the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the adjunctive procedure and to pay more for the extraction provided on January 22, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on December 3, 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 separately payable.
The Plan must follow Medicare rules. The rules say that, for edits with a modifier indicator of 0, the Column 2 code is not payable. The provider submitted a claim for procedure codes 99231 and 01402. Code 99231 is a column II code with a modifier indicator of 0 when billed with column I code 01402. Code 99231 is not separately payable.
Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered on December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary tissue conditioning (D5850).
You asked the Plan to pre-approve the maxillary tissue conditioning. 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 pre-approve a maxillary tissue conditioning (D5850).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81404, 81413, 81442, 81238) provided October 9, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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. We find that CPT code 81404, 81413, 81442, & 81238 is not supported in the medical record. Specifically, the records provided do not have the same date of service as the claim submitted. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81404, 81413, 81442, 81238) provided October 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for routine transportation trips to the requested physician's office.
You asked the Plan to provide coverage for the routine transportation trips. You say that the enrollee needs transportation outside of the 50-mile approved zone to come in person for her pulmonary appointments. You say that there are no providers within a 50-mile distance of the enrollee's home who treat her diagnosis and it is
essential that she comes in person to her appointments to be properly assessed, treated and diagnosed. The Plan denied your request. The Plan says that based on the Plan's routine transportation benefit, you are requesting an additional 8.1 miles for a total of 58.1 miles and the Plan's benefit only allows that each one-way trip must not exceed 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving distance. We looked at your request, the records in the case file, and the rules. The file shows that you are requesting an additional 8.1 miles, for a total of 58.1 miles per one-way trip. The Plan benefit only allows 50 miles per one-way trip. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide coverage for routine transportation trips to the requested physician's office.
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 August 12, 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 August 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (36415, 84443, 80053, 80061) provided on February 10, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 lab services (36415, 84443, 80053, 80061) provided on February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network durable medical equipment provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is a requirement to use in-network providers.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network durable medical equipment provider.