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

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on January 12, 2021.
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for durable medical equipment. The enrollee has been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $402.58. The total amount you are being asked to pay is $80.52 ($402.58 x 20% = $80.52). The correct coinsurance has been applied. Durable medical equipment falls within the durable medical equipment benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in
the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), three additional intraoral periapical x-rays (D0230 x3), bitewing x-rays (D0274), preventive procedure (D1999), and two extractions (D7140 x2) provided on September 3, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation, intraoral periapical x-rays, bitewing x-rays, preventive procedure, and extractions. You say that you thought these services would be covered. The Plan denied your request. The Plan says these services are not covered. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), three additional intraoral periapical x-rays (D0230 x3), bitewing x-rays (D0274), preventive procedure (D1999), and two extractions (D7140 x2) provided on September 3, 2020.
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 11, 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 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames (V2020), and lenses (V2201 x2) received on December 10, 2020.
You asked the Plan to pay for frames and lenses. You say that you want to be reimbursed for both pairs of eyeglasses you received. The Plan denied your request. The Plan says the annual amount allowed under your benefit was exceeded.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of frames and lenses have not been met. Specifically, the annual amount allowed under your benefit was exceeded. Therefore, we decided that the Plan does not have to pay for frames (V2020), and lenses (V2201 x2) received on December 10, 2020.
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 25, 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 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J1955 is injection, levocarnitine, per 1 gm. We find that HCPCS/CPT code 97016 is 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 for treatment with a Sanexas device. Payment for HCPCS/CPT codes 96372 and J1955 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 25, 2020.
Appeal type: Other
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 3, 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 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ingrezza capsules, 80 mg.
You asked the Plan to pre-approve Ingrezza. You say that the enrollee has been stable on this medication since April 2021. You say that the enrollee has not had any negative side effects. You also say that other medications show an inadequate response. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ingrezza capsules, 80 mg. Benefits for Ingrezza may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to hold you harmless for paramedic intercept services, rural area (A0432) received October 31, 2020.

You asked the Plan to hold you harmless for paramedic intercept services. You say that you were not transported by the ambulance. The Plan denied your request. The Plan says that since you were not transported by this ambulance, the service is not covered under your plan.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.

You received paramedic intercept services from a contract provider. The file does not show that the Plan provided notice that paramedic intercept services would not be covered. The EOC does not serve as adequate notice of non-coverage in this case. Under Medicare rules, this means paramedic intercept services are considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for paramedic intercept services, rural area (A0432) received October 31, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you do not agree with these charges. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 items/services at issue in this appeal. 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 lab work provided on February 4, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the inpatient stay provided from January 22, 2021, through January 26, 2021.

You asked the Plan to waive the cost for the inpatient stay. You say that you are appealing the inpatient stay because the provider billed occupational and physical therapy. You say that you couldn't have had physical or occupational therapy when you just had surgery. The Plan denied your request. The Plan says the cost share applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the combined deductible amount, you must pay the full cost for most of your covered services. Your contract with the Plan also says that you must pay a $300 copayment per admission after the deductible is met for each medically necessary inpatient stay. 

The item or service you asked the Plan to waive the deductible for falls within the "Inpatient hospital care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time the inpatient stay was received on January 22, 2021 to January 26, 2021. Therefore, $670.24 has been applied to meet your deductible.

Since the $750 deductible was met, you have also been asked to pay a $300 copayment for the inpatient stay. 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 for the inpatient stay provided from January 22, 2021, through January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cup holder for the approved power wheelchair.

You asked the Plan to pre-approve a cup holder. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a cup holder is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a cup holder for the approved power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the biopsy and related services provided on April 9, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the biopsy and related services. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 the biopsy and related services provided on April 9, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral swabs.
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your
request. The Plan says this is a hygienic item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve oral swabs.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on October 23,
2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.

We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid diagnosis
code. 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 emergency room (ER) services rendered on October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on January 26, 2021.
You asked the Plan to pay for an eye refraction. You say that the service should be covered, and you want the Plan to pay. The Plan denied your request. The Plan says the service at issue is not a covered benefit. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Specifically, eye refractions are not a covered benefit. The record shows you signed a consent form on January 26, 2021 acknowledging the refraction fee was $65 and was due at the time of service. You also acknowledged in the consent form that a refraction is a non-covered service with Medicare and most insurance Plans. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic pressure device(E0673) provided November 2, 2020.

You asked the Plan to pay for pneumatic pressure device. You say that the records provided should support the medical necessity of the service in dispute. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

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 enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of pneumatic pressure device have not been met. Therefore, we decided that the Plan does not have to pay for the segmental gradient pressure pneumatic pressure device(E0673) provided November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 10, 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 covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 86077 is 1. You billed 2 units of this code, exceeding the MUE. 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 laboratory services rendered on November 10, 2020.