Persius/hicric huggingface dataset:
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 8, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that 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 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. 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. The HCPCS/CPT Code Manual definition of code J1955 is injection, levocarnitine, per 1 gm. We find that HCPCS/CPT codes 97016, 97032, and 97112 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 a therapeutic procedure for neuromuscular reeducation for sitting or standing activities was performed. There is no mention of therapy to perform these functions; the stimulation provided by the Sanexas device does not satisfy the requirements to report CPT code 97112. 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 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond May 7, 2021.

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 continued services are not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF after hospitalization for left foot osteomyelitis and left below knee amputation. He received oral medications and insulin and had stable vital signs. He received physical and occupational therapy in the SNF. By the dates in question, he needs supervision to maximal assistance with functional mobility and varied assistance with activities of daily living. He has skilled nursing needs but does not require skilled nursing on a daily basis. He does not have skilled therapy needs. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the oral exam and cleaning provided by an out of network (OON) dentist on December 15, 2020.

You asked the Plan to make additional payment for the OON dental services. You say that you were not told that there was any cap on dental services from your sale representative. You feel that this should be covered in full since you were not informed. The Plan denied your request. The Plan says your contract indicates that payment is based on the plan's allowable for OON dental care. Since this provider charges more than the plan's allowable, this is your responsibility.

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, payments for OON dental care are based on the plan's allowable amount for the service. If the provider charges more than this amount, you are responsible for the difference. Therefore, we decided that the Plan does not have to make additional payment for the oral exam and cleaning provided by an out of network (OON) dentist on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on October 6, 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 there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 neuromuscular stimulator rendered on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the service is considered unproven.
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 requested services. Our physician reviewer found that the enrollee has sacroiliitis documented by physical examination. She takes Gabapentin, Diclofenac, Tramadol, and Tizanidine for pain. She is doing a home exercise program. The request is for radiofrequency ablation of the lateral sacral branches for SI joint pain. This is considered an experimental/ investigational procedure due to the wide variation in efficacy reported in the peer reviewed literature. Therefore, the request is considered not medically reasonable or 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a transcervical radiofrequency ablation with ultrasound guidance using the Sonata System.

You asked the Plan to pre-approve a transcervical radiofrequency ablation with ultrasound guidance using the Sonata System. You say that the requested transcervical radiofrequency ablation with ultrasound guidance using the Sonata System is medically necessary. The Plan denied your request. The Plan says that the requested transcervical radiofrequency ablation with ultrasound guidance using the Sonata System is 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 a transcervical radiofrequency ablation with ultrasound guidance using the Sonata System. Our reviewer says that the requested transcervical radiofrequency ablation with ultrasound guidance using the Sonata System is medically necessary. Our physician reviewer found the enrollee is with long, heavy periods and dysmenorrhea due to multiple fibroids. The menses lasts between 7 and 20 days and is associated with very heavy bleeding and intense cramping pain. A pelvic ultrasound demonstrated multiple myometrium fibroids, the largest measuring 3.3 x 3.4 x 2.7 cm. The enrollee's diagnoses include Anemia, unspecified, Abnormal uterine and vaginal bleeding, unspecified, Leiomyoma of uterus, unspecified, and Unspecified dyspareunia. The enrollee does not want a hysterectomy at this time and does not want hormone therapy.

The controlling rule in this case is based upon the Social Security Act Section 1862(a)1(A) that defines when a service is medically necessary, in the absence of a National or Local Coverage Decision. Radiofrequency ablation of uterine fibroids, including via a transcervical approach, has been shown to significantly reduce fibroid volume, provide significant durable improvements in fibroid-related quality of life, and is associated with favorable reintervention rates.

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 transcervical radiofrequency ablation with ultrasound guidance using the Sonata System have been met. Therefore, we decided that the Plan has to pre-approve a transcervical radiofrequency ablation with ultrasound guidance using the Sonata System.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve the ESI. We decided that the Plan does not have to pre-approve MAC.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that the services are not medically necessary.
We decided that the Plan has to pre-approve the ESI.
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. The rules say that an ESI is covered when specific criteria are met. 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 ESI is medically necessary and the MAC is not medically necessary. Our physician reviewer found you have sciatica and are taking pain medications. You have had physical therapy. The criteria for coverage of the ESI are met and the services are medically necessary. There is no documentation of a prior failed attempt at oral sedation. The MAC is not reasonable or medically necessary for the ESI procedure. 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 ESI have been met. Therefore, we decided that the Plan has to pre-approve the ESI.
We also decided that the Plan does not have to pre-approve MAC.
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 ESI is medically necessary and the MAC is 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 MAC have not been met. Therefore, we decided that the Plan does not have to pre-approve MAC.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from January 29, 2020, through February 3, 2020 billed with Diagnosis-Related Group (DRG) 579.
You asked the Plan to pay for the inpatient hospital care as billed. You say that it is felt that this was billed correctly and should be paid at DRG 579. The Plan denied your request. The Plan says it is felt that the correct DRG for this admission would be 130.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with principal diagnosis squamous cell carcinoma of the face, and secondary diagnosis code R65.11, defined as Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction. 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 the inpatient hospital care as billed. Our reviewer says that the billed diagnosis codes are not supported in the medical records. Our physician reviewer found the patient was an 80-year-old male with history of atrial fibrillation and with metastatic squamous cell carcinoma who presented to the hospital for a scheduled resection on 1/29. He underwent extensive head and neck surgery complicated only by tachycardia following the operation, but otherwise was recovering well without symptoms. Blood pressure remained normal. Given fluids and medication adjusted from carvedilol to metoprolol. No evidence to suggest lactic acidosis was related to sepsis or SIRS. The primary admission diagnosis appears to be either atrial fibrillation with rapid ventricular response (RVR) or lactic acidosis. The records did not support the diagnosis of SIRS. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from January 29, 2020, through February 3, 2020 billed with Diagnosis-Related Group (DRG) 579.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on December 9, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says you had exceeded the maximum number of this type of service allowed for a given time period. The Plan also says that you did not contact the Plan in regard to your cost share or provider questions for this service.
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, you are limited to two exams per calendar year. The record shows that you received periodic oral exams (D0120) on July 17, 2020, and November 12, 2020 and your exams benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on December 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF services. The Plan denied your request. The Plan says your care needs may be met in the skilled nursing facility setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on August 9, 2020.

You asked the Plan to pay for the MRI. The Plan denied your request. The Plan says screening tests are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, the MRI, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on August 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 27, 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 October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) provided on November 17, 2020.

You asked the Plan to pay for the dental service. You say that you do not understand why this service is not covered. You also say that it was covered last year. The Plan denied your request. The Plan says core build up is not listed as a covered service.

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 core build up (D2950) provided on November 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for cellulitis of right great toe and had amputation of the toe. He was treated for cholecystitis and urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.