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

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device.
You asked the Plan to pre-approve interspinous spacer device. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the interspinous spacer device is experimental/investigational.
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 interspinous spacer device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process distraction devices remain experimental for use in spinal surgery. More research is needed to show the safety and efficacy of this device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Privigen.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found you have a history of systemic lupus and haves tried and failed multiple anti-rheumatic disease modifying agents. The use of Privigen to treat your diagnosis meets the Medicare criteria for coverage. The requested services are reasonable and medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve Privigen.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81404, 81405, 81406, 81479) provided on November 27, 2020.
You asked the Plan to pay for a comprehensive cardiovascular genetic panel. You say that this should be covered. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive cardiovascular genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81404, 81405, 81406, 81479) provided on November 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Computed Tomography (CT) Colonography.
You asked the Plan to pre-approve the CT Colonography. You say that the service is medically necessary. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. Medicare rules say that Screening computed tomographic colonography (CTC) is not covered. We looked at the file and Medicare rules. The requested service is not a covered benefit. Based on this information, we decided that Medicare rules for coverage of the CT Colonography have not been met. Therefore, we decided that the Plan does not have to pre-approve a Computed Tomography (CT) Colonography.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded 99238 provided on February 21, 2020.
You asked the Plan to pay for the hospital discharge day management services. 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 supported by the documentation.
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 99238 is hospital discharge day management; 30 minutes or less.
We find that CPT code 99238 is not supported in the medical record. Specifically, the documentation submitted does not include a hospital discharge day management note with a recorded duration of time of 30 minutes or less for the billed date of service. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services coded 99238 provided on February 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you are a fall risk and need care at a SNF. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is consistently ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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 10, 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 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiovascular panel testing provided on November 30, 2020.
You asked the Plan to pay for the services provided. You say that the results of the testing allow physicians to effectively make treatment decisions. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. We looked at the file and the rules. In this case, there are insufficient records to show that the treating physician will use the results in the management of the enrollee's specific medical problem. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiovascular panel testing provided on November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair repairs.
You asked the Plan to pre-approve the repairs. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not cover repairs when the expense for repairs exceeds the estimated expense for replacement of the wheelchair.
The Plan must follow Medicare rules. Medicare rules say that DME repairs are not covered if the cost exceeds what replacing the item would cost. The cost of the requested wheelchair repairs ($3145.36) exceeds the allowable amount for a new power wheelchair ($2681.04). Based on this information, we decided that Medicare rules for coverage of the repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair repairs.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260).

You asked the Plan to pre-approve the osseous surgery. You say that you are in pain and the surgery is medically necessary. The Plan denied your request. The Plan says this service is not covered under you 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 pre-approve the osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the reduction of eye prosthesis (V2626) and the polishing artificial eye (V2624) provided on June 9, 2020.
You asked the Plan to pay for the vision care services. You say that the enrollee has 100% prosthetic coverage. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the reduction of eye prosthesis (V2626) and the polishing artificial eye (V2624) provided on June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on December 1, 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 procedure codes J3411, J3415, and J3490 are not supported.
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 J3411 is injection, thiamine hcl, 100 mg. The definition of code J3415 is injection, pyridoxine hcl, 100 mg. The definition of code J3490 is unclassified drugs. We find that CPT codes J3411, J3415, and J3490 are not supported in the medical record. Specifically, the
records show that a nutria-pharmaceutical blend was administered and each code cannot be billed separately. 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 injection services rendered on December 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the certolizumab (Cimzia) injection provided from August 18, 2020, to December 28, 2020.
You asked the Plan to waive the cost share for the Cimzia injection. You say that you did not know you had a coinsurance. The Plan denied your request. The Plan says the claims processed 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 20% coinsurance for Medicare Part B prescription drugs. The file shows that you received injections on August 18, 2020, September 28, 2020, November 30, 2020, and December 28, 2020. You have been asked to pay a 20% coinsurance for the Cimzia injection on each date of service. The 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 cost share for the certolizumab (Cimzia) injection provided from August 18, 2020, to December 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on September 16, 2020.
You asked the Plan to pay for therapeutic exercises. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says there is a more appropriate code for the services provided.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the record shows that the services at issue were performed by a qualified physical therapist assistant in the home health setting. There is a
more appropriate code (G0157) for these services. Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous moderate sedation/analgesia (D9239,
D9243).
You asked the Plan to pre-approve sedation/analgesia. You say that the sedation/analgesia is necessary to
perform other services. The Plan denied your request. The Plan says this service is not covered under 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
intravenous moderate sedation/analgesia (D9239, D9243).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts (L3000).
You asked the Plan to pre-approve the foot inserts. You say that your doctor says you need the inserts for foot pain. The Plan denied your request. The Plan says there is no documentation you use a leg brace or that the orthotics are needed for the proper functioning of a brace attached to a shoe.
The Plan must follow Medicare rules. Medicare rules say that for any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. We looked at the file and Medicare rules. The records do not show you use a brace. Based on this information, we decided that Medicare rules for coverage of the foot inserts have not been met. Therefore, we decided that the Plan does not have to pre-approve foot inserts (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a panoramic radiographic image (D0330) provided on October 22, 2020.
You asked the Plan to pay for a comprehensive oral evaluation, and a panoramic radiographic image. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the services are a covered benefit, but you have exceeded the frequency limit of one every 3 Plan years.
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 comprehensive oral evaluation, and a panoramic radiographic image have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on October 18,
2018. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a panoramic radiographic image (D0330) provided on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological comprehensive medical examination with continuation of diagnostic and treatment program (92014) received January 25, 2021.
You asked the Plan to waive the copayment for the ophthalmological comprehensive medical examination with continuation of diagnostic and treatment program. You say that this was a routine eye exam and should have no copayment. The Plan denied your request. The Plan says the service as billed indicates this exam was intended to diagnose or treat conditions of the eye.
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 $40 copayment for an exam to diagnose and treat diseases and conditions of the eye.
You have been asked to pay a $40 copayment for the ophthalmological comprehensive medical examination with continuation of diagnostic and treatment program. The ophthalmological comprehensive medical examination falls is classified as an exam to diagnose and treat diseases and conditions of the eye. 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 ophthalmological comprehensive medical examination with continuation of diagnostic and treatment program (92014) received January 25, 2021.