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

We decided that the Plan does not have to preapprovea Dexcom therapeutic continuous glucose monitor system (CGM)(K0554).You asked the Plan to preapprovethe CGM. You say that you don't like your current CGM; the sensor is on your arm which you believe is causing you to lose it. You believe the Dexcom will be better suited for you.The Plan denied your request. The Plan says there is no evidence your device is malfunctioning, so it will not approve a new device.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 ownsa functioning CGM that is under warranty till 2025. Coverage criteria of a new Dexcom CGM have not been met.Therefore, we decided that the Plan does not have to preapprovea Dexcom therapeutic continuous glucose monitor system (CGM)(K0554
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97530) provided December 21, 2020.
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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 CPT Code Manual definition of code 97530 is Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the records do not detail how much time was spent on this service. Based on this information, we decided that Medicare rules for coverage of
the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97530) provided December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities services coded 97530 provided on July 30, 2020.
You asked the Plan to pay for the therapeutic activities services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows that these services were performed by an occupational therapist assistant in a home health or hospice setting. There is a more appropriate code to bill for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities services coded 97530 provided on July 30, 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 October 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 October 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on December 8, 2020.
You asked the Plan to pay for the testing services. You say that the services were provided by a physician not employed by the enrollee's hospice provider. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on December 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services provided on December 13, 2020 to December 20, 2020.

You asked the Plan to pay for the services provided. You say that the enrollee was not safe for discharge. The Plan denied your request. The Plan says the enrollee does not have the benefit to cover an authorization for this hospital stay.

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 provider in this case is not a network provider with the Plan. 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 inpatient psychiatric services provided on December 13, 2020 to December 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) any joint of lower extremity (73721) provided September 14, 2020.

You asked the Plan to waive the copayment for the MRI. You say that you were told by a plan rep that it would cost $250 total. Based on the fact that you were given incorrect information you feel that the plan should cover the extra $250. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 $250 copay for covered diagnostic radiology services in a provider's office or freestanding radiology center.

You have been asked to pay $250 copay 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 magnetic resonance imaging (MRI) any joint of lower extremity (73721) provided September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided November 9, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says the criteria for coverage was not met for these items.
The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found that the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on the enrollee's knee, there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete denture - mandibular (CPT Code D5120 X1),
complete denture - maxillary (CPT Code D5110 X1), gingival irrigation - per quadrant (CPT Code D4921 X2),
dental extractions (CPT Code D7210 X17), alveoloplasty in conjunction with extractions - four or more teeth
or tooth spaces, per quadrant (CPT Code D7310 X4) and unspecified adjunctive procedure, by report (CPT
Code D9999 X2).

You asked the Plan to pre-approve the dental services. You say that you were told you have an infection, gum
disease and bone loss. You state you will need to get all of your teeth extracted and receive dentures. The Plan
denied your request. The Plan says the 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.

Review of the file shows that gingival irrigation - per quadrant (D4921 X2), alveoloplasty in conjunction with
extractions - four or more teeth or tooth spaces, per quadrant (D7310 X4), and unspecified adjunctive
procedure, by report (D9999 X2) are not covered benefits. Furthermore, complete denture - mandibular (D5120
X1), complete denture - maxillary (D5110 X1), and dental extractions (D7210 X17) are not covered because
you exhausted your benefits for each service. You were approved for two (2) dental extractions, teeth #3, and
#4 (CPT Code D7210 X2), immediate denture - maxillary (CPT Code D5130), and immediate denture -
mandibular (CPT Code D5140) on April 7, 2021. Therefore, we decided that the Plan does not have to preapprove
complete denture - mandibular (CPT Code D5120 X1), complete denture - maxillary (CPT Code
D5110 X1), gingival irrigation - per quadrant (CPT Code D4921 X2), dental extractions (CPT Code D7210
X17), alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (CPT
Code D7310 X4) and unspecified adjunctive procedure, by report (CPT Code D9999 X2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.

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. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 

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 long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forambulance transportation services provided on December 11, 2020.You asked the Plan to waive the copayment forambulance transportation services. You say that you disagree with the charges.The Plan denied your request. The Plan says the copayment you are being charged is correct.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 $330 copayment for each one-way ambulance transport received out-of-network. You have been asked to pay a $330 copayment for ambulance transportation services. The EOC is clear that $330 is the required copayment for this service. 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 forambulance transportation services (A0426, A0425) on December 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of
service criteria for an inpatient basis in a skilled nursing facility setting.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
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 necessary. The Plan denied your request. The Plan says based on the documentation provided, 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 the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Unfavorable

We decided that the Plan does not have to pre-approveradiofrequency ablation to the sacroiliac joint (64625).You asked the Plan to pre-approveradiofrequency ablation to the sacroiliac joint. You say that this request is medically necessary.The Plan denied your request. The Plan says the clinical value and effectiveness of radiofrequency ablation to the sacroiliac joint in the setting of sacroiliitis has not been demonstrated.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 radiofrequency ablation to the sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found both radiofrequency ablation of the lateral sacral branches and the genicular nerves are considered experimental/ investigational. 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 radiofrequency ablation to the sacroiliac joint have not been met.Therefore, we decided that the Plan does not have to pre-approveradiofrequency ablation to the sacroiliac joint (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased November 5, 2020.
You asked the Plan to pay for the hearing aids. You say that it is your understanding the Oticon hearing aids
are the newest and premium technology. Therefore, you will see on the reimbursement form you have
requested $1500 reimbursement for each hearing aid. The Plan denied your request. The Plan says the hearing
aids purchased were not covered devices under the hearing aid formulary.
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 coverage for hearing aids is limited to the designated in-network vendor and you must choose
a device that is included on the hearing aid formulary.
We looked at the file, and the Plan's rules. 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 purchased November 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flex-walk system lower extremity prostheses (L5981).
You asked the Plan to pre-approve the prosthesis. You say that the enrollee needs the increased support given by the K3 carbon footplate provided by the L5981 foot to help increase his balance and safety while he begins his rehabilitation as a bilateral amputee. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for coverage.
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 prosthesis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for bilateral transtibial amputee. A 2/11/21 telehealth exam he was noted to be ready for his right prosthesis and was seen on 3/4/21 for fitting/evaluation. However, on both 2/11/21 and 3/4/21 evaluations, he is noted to be expected to be a level K3 functional level (with current K level noted as K1 on 3/4/21). Therefore, the medical records provided do not meet the requirements listed in the LCD for Medicare coverage of the requested right lower extremity prosthetic (L5981). 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 prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a flex-walk system lower extremity prostheses (L5981).