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 October 13, 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 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating
provider on December 16, 2020.

You asked the Plan to waive the copayment for lab work. You say that you have never had to pay for this
before. The Plan denied your request. The Plan says the correct copayment 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). Your contract with the Plan clearly says that you must pay a $50
copayment for outpatient diagnostic tests/in-network/lab services/outpatient hospital.

You have been asked to pay a $50 copayment for lab work. When additional services are provided during an
office visit, additional copayments are applied; therefore, the correct copayment has been applied. Lab work
falls within the outpatient diagnostic tests/in-network/lab services/outpatient hospital 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 lab work provided by a participating provider on December 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Protonix.

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 self-administered drugs are not covered.

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 Protonix.

Benefits for these services 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81404, 81405, 81408) provided on September 26, 2020.

You asked the Plan to pay for genetic testing. You say that these services were provided in good faith. The Plan denied your request. The Plan says these services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that as Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX, and it is a test not currently satisfactorily described by any existing CPT code. Therefore, to report a CGP service, test providers should use CPT code 81479 at this time. 

We find that CPT codes 81404, 81405, 81408 are not supported in the medical record. Specifically, this testing is considered a CGP service and should be billed with 81479. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81404, 81405, 81408) provided on September 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5257), ear impression (V5257) and unspecified procedure or service (99199) provided on November 6, 2020 to November 16, 2020.

You asked the Plan to pay for the hearing services. You say that you understand that the Plan only reimburses hearing aids every 3 years, but your hearing deteriorated and new ones were necessary. The Plan denied your request. The Plan says you previously received hearing aids in November 2019, which exceeds the frequency allowed by your benefit allowance. The hearing aid services cannot be covered. In addition, the unspecified procedure or service is not covered under this benefit.

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 up to $5,000 for hearing aids only once every 3 years. 

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 services have not been met. The services are either not covered under the benefit or are requested in a frequency that exceeds what is allowed by the benefit. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5257), ear impression (V5257) and unspecified procedure or service (99199) provided on November 6, 2020 to November 16, 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 16, 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 16, 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 23, 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 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided by a participating provider on October 29, 2020.

You asked the Plan to waive the copayment for an injection. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment 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). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery/outpatient hospital facility. 

You have been asked to pay a $250 copayment for an injection. The injection that was provided is considered an outpatient surgery; therefore, the correct copayment has been applied. An injection falls within the outpatient surgery/outpatient hospital facility 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 an injection provided by a participating provider on October 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).

You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that the requested genicular nerve radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the requested genicular nerve radiofrequency ablation is not medically necessary.

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 genicular nerve radiofrequency ablation. Our reviewer says that the requested genicular nerve radiofrequency ablation is not medically necessary. Our physician reviewer found the enrollee has pain in her knees bilaterally due to osteoarthritis. She is taking Percocet and Norco, as well as Celecoxib, ibuprofen, Gabapentin and Duloxetine. She had a right total knee replacement (TKR) on 5/27/2020. She had one set of genicular nerve blocks which produced 60% pain relief for one week. She had a second set of genicular nerve blocks which produced 75-80% pain relief for a month.

The requested genicular nerve radiofrequency ablation is considered an experimental/investigational procedure as there are still clinical trials going on to determine the role of genicular RFA in the management of pain post-surgical TKR. 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 genicular nerve radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services rendered from July 28, 2020 to August 14, 2020.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was applied correctly.

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 $0 copayment for days 1-20 and a $178 copayment per day for days 21-100 for in-network SNF care.

Review of the file shows that you received four days of SNF care from July 28, 2020 to July 31, 2020. You have been asked to pay a $178 copayment per day for these services, for a total of $712. These services fall within the in-network SNF care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The file shows that you received 14 days of SNF care from August 1, 2020 to August 14, 2020. You had two days remaining in the $0 copayment for days 1-20 at the time this claim was processed; therefore, a copayment of $178 per day for 12 days was applied, for a total of $2,155. These services fall within the in-network SNF care 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 skilled nursing facility (SNF) services rendered from July 28, 2020 to August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on May 15, 2020, to November 24, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you think this is being billed incorrectly. 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 Medicare Part B prescription drugs/in-network. 

The enrollee has been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $2,489.36. The total amount you are being asked to pay is $497.88 ($2,489.36 x 20% = $497.88). The correct coinsurance has been applied to the injections that were provided. An injection falls within the Medicare Part B prescription drugs/in-network 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 an injection provided by a participating provider on May 15, 2020, to November 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided November 3, 2020.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the CPT codes billed are not separately payable.

The Plan must follow Medicare rules. Medicare rules say that two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. 

We looked at the file and Medicare rules. The tests performed were unbundled and multiple CPT codes were billed. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750) provided on January 25, 2021.

You asked the Plan to pay for the crown. You say that you would like this service to be covered. The Plan denied your request. The Plan says this procedure is not covered under your dental plan.

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 crown (D2750) provided on January 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on September 9, 2020.

You asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says self-administered drugs are not covered by 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 pay for the self-administered drugs provided on September 9, 2020.

Benefits for the self-administered drugs 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 pay for advanced life support, level 2 (A0433, A0425) provided on
October 19, 2020.

You asked the Plan to pay for the advanced life support, level 2 (A0433, A0425). The Plan denied your request.
The Plan says that ambulance transport after death is not a Medicare covered benefit.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.

We looked at the file and Medicare rules. There is no evidence that the enrollee's time of death was
pronounced prior to the ambulance leaving the scene for the hospital. Therefore, we decided that the Plan has
to pay for advanced life support, level 2 (A0433, A0425) provided on October 19, 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.