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 September 30, 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 30, 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 services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.

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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for office visit services (CPT 99213) provided to the enrollee on January 15, 2021.
You asked the Plan to pay for the services. You say that POS 12 (home) is an allowable location for all temporary telephonic codes. The Plan denied your request. The Plan says that POS 12 (home) is not an appropriate location for these services.
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 99213 is "office or other outpatient visit for the evaluation and management of a new patient." We looked at the the file, and Medicare rules and decided that CPT 99213 is supported. The file shows that the office visit was telephonic, therefore, a place of service of "Home" would be appropriate in this case. Additionally, part of the plan's denial is that the submitted documentation does not support the visits as being performed by the billed provider on the date of service at issue in this case. There is nothing in the case file to suggest this. The plan has not substantiated their denial. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for office visit services (CPT 99213) provided to the enrollee on January 15, 2021.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Botox 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
you do not have a condition for which Botox is covered. Our physician reviewer found the records show that
you have a hernia without obstruction or infection. You are awaiting hernia repair surgery. Botox is not
covered for this condition and is not reasonable or 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 not been met. Therefore, we decided that the Plan does not
have to pre-approve Botox.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Magnetic resonance imaging (MRI) scan of the brain.
You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested MRI scan is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI scan. Our reviewer says that the documentation does support that the requested services are medically reasonable and necessary. Our physician reviewer found the enrollee has cognitive and memory impairment. An MRI from 2018 demonstrated microangiopathy. A recent physical examination does not demonstrate neurological deficit. The provided medical records indicate that the enrollee is having increasing difficulty speaking. The medical records provided are sufficient to establish the medical reasonableness and necessity of an MRI as defined by Medicare rules. Therefore, the enrollee meets criteria for the requested 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 an MRI scan have been met. Therefore, we decided that the Plan has to pre-approve a Magnetic resonance imaging (MRI) scan of the brain.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bifocal lens (V2209), anti-reflective coating, per lens (V2750), progressive lens, per lens (V2781), plastic or glass lens (V2782), eye and medical exam for diagnosis and treatment, established patient (92014), assessment for prescriptive eye wear using a range of lens powers (92015) and not medically necessary service (S9986) provided December 29, 2020.
You asked the Plan to pay for the bifocal, anti-reflective, progressive, plastic or glass lenses, eye exam, eye wear assessment and not medically necessary service. You say that you believe you had vision coverage in 2020 and should be reimbursed. The Plan denied your request. The Plan says you did not purchase supplemental vision benefits in 2020; therefore, your routine vision services and eyewear are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services and eyewear. Therefore, we decided that the Plan does not have to pay for the bifocal lens (V2209), anti-reflective coating, per lens (V2750), progressive lens, per lens (V2781), plastic or glass lens (V2782), eye and medical exam for diagnosis and treatment, established patient (92014), assessment for prescriptive eye wear using a range of lens powers (92015) and not medically necessary service (S9986) provided December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Verio test strips.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are available from the preferred provider.
The Plan must follow Medicare rules. The rules say that Plans may limit enrollees to preferred providers for
durable medical equipment and supplies.
We looked at the file and Medicare rules. The services at issue are test strips from a non-preferred provider.
The Plan has diabetic testing supplies available from the preferred providers. Therefore, we decided that the
Plan does not have to pre-approve OneTouch Verio test strips.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgical services provided on November 16, 2020, by an out-of-network provider.

You asked the Plan to waive the copayment for the services. You say that you called the plan prior to having the service done to ask if you will have a copayment for the colonoscopy. You state you were told there would be no copayment for this colonoscopy. The Plan denied your request. The Plan says they reviewed the call and you were advised there is a $370 copayment for outpatient surgery services done in a hospital.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

Review of the file shows that you received services on November 16, 2020. The plan applied a copayment to esophagogastroduodenoscopy (CPT code 43239). The provider billed code 43239 in the amount of $2,050.50. The allowed amount for code 43239 was $736.41. The plan processed the claim according to the in-network benefits. The plan applied a $370.00 outpatient hospital surgery benefit copayment to code 43239. The plan also billed a diagnostic colonoscopy (CPT code 45378). The plan did not apply any copayment to the colonoscopy service. CPT code 43239 is classified as a surgical procedure. The plan applied the correct outpatient surgery copayment to code 43239. You are responsible for a $370 copayment. Your 2020 EOC states, "says that enrollees must pay a $0 copayment for a diagnostic colonoscopy at an outpatient hospital. Enrollees must pay $370 copayment for in-network Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges." This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgical services provided on November 16, 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 hearing aids (V5267, V5298) received June 25, 2020.

You asked the Plan to pay for the hearing aids. You say that the hearing aids are necessary. The Plan denied your request. The Plan says hearing aids purchased outside of the Plan's hearing vendor network are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from a plan-participating hearing network vendor. 

We looked at the file, and the Plan's rules. You purchased the hearing aids from a vendor who does not participate in the Plan's hearing network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5267, V5298) received June 25, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency ambulance transport services provided on
October 23, 2020.
You asked the Plan to pay for the non-emergency ambulance transport 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 non-emergency ambulance transport services provided on
October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99284) provided on December 23, 2020.

You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim denied because the Plan is not the member's primary insurance,

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the emergency department visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) provided on December 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the advanced life support, emergency transportation (A0427) provided on February 10, 2021.
You asked the Plan to pay for the ambulance services. You say that this was a 911 emergency call. You say that the enrollee was triaged to basic life support (BLS) for transport to the Emergency Department. The Plan denied your request. The Plan says the location of the intercept was not a rural area. The Plan also says that the provider did not transport the enrollee to the hospital.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York.
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the advanced life support, emergency transportation (A0427) provided on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam image capture (D0364) provided on March 11, 2021.
You asked the Plan to pay for the cone beam image capture. You say that you were not told that this service would not be covered and feel it would not have been necessary if it wasn't for previous unsatisfactory dental work provided by a previous dentist. The Plan denied your request. The Plan says this service is not covered by the Plan's 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 pay for a cone beam image capture (D0364) provided on March 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on January 5, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you were told the MRI would be covered. You say if you knew there was a copayment, you would not have had the MRI. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per visit for all other outpatient diagnostic and therapeutic services and supplies, such as MRAs, MRIs, CT scans, PET scans, and hyperbaric oxygen therapy. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $250 copayment for the MRI.
You have been asked to pay a $236.02 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the MRI provided on January 5, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a knee
fracture after a fall. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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.