Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the rental charge for the neuromuscular electrical stimulator (NMES) device billed with date of service August 31, 2020.

You asked the Plan to pay for the NMES device rental. You say that the documentation supports the billing of this claim. The Plan denied your request. The Plan says there is not sufficient evidence to support that criteria for payment are met.

The Plan must follow Medicare rules. Medicare rules say that for DME suppliers using a delivery services, either the date of shipping or the date the item is received by the enrollee may be used for the DOS. The rules also note that for continuous use items, claims should be billed on a monthly basis.

The date of service for this rental charge is not supported by the documentation. The invoice shows that this item was shipped on March 5, 2020, and was delivered to the enrollee on March 9, 2020. As such, one of these two dates would be the date for the first month's rental of this item, which would be billed on a monthly basis. Another document in the file indicates that the first date of service for this item was May 31, 2020, which is not supported by the shipping/delivery documentation. Since this rental payment is not being billed at a monthly interval from the shipping/delivery date, the claim is not supported as billed. Therefore, we decided that the Plan does not have to pay for the rental charge for the neuromuscular electrical stimulator (NMES) device billed with date of service August 31, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. The Plan denied your request. The Plan says
there is no clinical evidence to support the medical necessity of this examination or that the member meets
Medicare criteria for continued PT therapy services.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 ten (10) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health
Plan. The enrollee has had extensive prior therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a
therapist. The enrollee has been instructed in and is compliant in a compression garment use. The requested
services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a
qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current
condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom continuous glucose monitor (CGM) sensors (K0553).

You asked the Plan to pre-approve Dexcom CGM sensors. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day and use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of Dexcom CGM sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom continuous glucose monitor (CGM) sensors (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 23, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a rental extension on a CPAP device.

You asked the Plan to pre-approve the extension. You say that this is medically necessary. The Plan denied your request. The Plan says there is a requirement for 70% compliance.

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 extension. Our reviewer says that the requested extension is not considered medically reasonable and necessary in this case. Our physician reviewer found the CPAP machine was ordered in August 2020. A compliance report from March 2021 demonstrates 53% compliance with use for greater than four hours per night. The record does not contain a clinical re-evaluation by the treating practitioner. The elements of the coverage rule are not satisfied.

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 extension have not been met. Therefore, we decided that the Plan does not have to pre-approve a rental extension on a CPAP device.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 2, 2020, through December 3, 2020.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an inpatient admission was not medically necessary.

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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that in this case, the enrollee who has end stage kidney disease, was brought to the emergency department from the rehabilitation facility due to guaiac positive stools and a downward trending hemoglobin. The enrollee was on dual anti-platelet therapy. The admission hemoglobin was 8.2 gm/dl, down from 9.6. The medical records provided indicate the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee's treatment and recovery just before the second midnight could not have been anticipated at admission. The elements of the coverage criteria are satisfied. The requested service is 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from December 2, 2020, through December 3, 2020.

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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on October 3, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 ambulance services provided on October 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 8, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met.

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed.

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 11, 2020 by an out of network provider.
You asked the Plan to pay for the office visit. You say that you would like the Plan to pay the claims at a contracted rate. The Plan denied your request. The Plan says you did not request prior authorization.
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 the office visit provided on June 11, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial dentures you received on January 11, 2021, and January 14, 2021.

You asked the Plan to pay for the partial dentures. The Plan denied your request. The Plan says this 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 services are not among those covered under this benefit. The Plan cover only oral exams, cleanings, bitewing x-rays, and emergency exams. Partial Dentures are not covered. Therefore, we decided that the Plan does not have to pay for the partial dentures you received on January 11, 2021, and January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on October 7, 2020.
You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on October 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 4, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 January 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and does
not require transfer LTACH.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. You continue
to receive acute care services and services have not been denied. The record does not indicate that you require
acute care services that you are not currently receiving that would be available at the LTACH facility. Our
physician reviewer found that your condition does not meet Medicare criteria for LTACH services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia provided by an out-of-network provider on November 24, 2020.

You asked the Plan to pay for the anesthesia. You say that the anesthesiologist is not responsible to obtain authorization for any of the procedures. You say that anesthesia is urgent for all procedures and the claim should be reprocessed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for anesthesia provided by an out-of-network provider on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM) (K0554).

You asked the Plan to pre-approve a Dexcom CGM. You say that this is medically necessary. The Plan denied
your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day and use insulin with at least three daily injections. Based on this
information, we decided that Medicare rules for coverage of a Dexcom CGM have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM) (K0554).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency care services provided on May 3, 2018.

You asked the Plan to pay for emergency care. You say that this claim was submitted within the timely filing
requirement. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because this claim was not submitted within the timely filing limit.

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 emergency care was not filed until December 4, 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 emergency care services provided on May 3, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the filling (D2335) provided on August 12, 2020.

You asked the Plan to reimburse you for the dental service. You say that the filling should be covered. You also say that you paid the dentist. The Plan denied your request. The Plan says your coverage only includes preventive services. The Plan also says that fillings are specifically excluded from coverage.

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 filling is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the filling (D2335) provided on August 12, 2020.