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 November 10, 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 November 10,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 28, 2020.

You asked the Plan to pay for the laboratory 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 payable.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 28, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on January 6, 2020.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance services provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the injections provided on December 18, 2020.

You asked the Plan to waive the cost share for the injections. You say that the billing should be reviewed, and nothing should be paid. 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 (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each Medicare-covered Part B drug and a $50 co-payment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules).

You have been asked to pay a total of $744.81 for the injections.

The pegfilgrastim injection falls within the "Medicare Part B Prescription Drugs" benefit category. The therapeutic injection falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" 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 cost share for the injections provided on December 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myocycle Home FES therapy system (functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups) (E1399).
You asked the Plan to pre-approve functional electrical stimulator. You say that the MyoCycle is proven to provide medical benefits to people with lower limb paralysis. The Plan denied your request. The Plan says the requested device is not medically necessary under Medicare guidelines.
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 functional electrical stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the enrollee is not noted to have a history of a SCI. Rather she has lower limb paralysis secondary to MS and CIDP. She is not noted to be ambulatory and requires a FES device for ambulation. In as much the requested item would not otherwise meet Medicare criteria for coverage 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 functional electrical stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve Myocycle Home FES therapy system (functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups) (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on
October 20, 2020.

You asked the Plan to pay for the home visit. You say that the physician depends on the hospital staff to verify
eligibility and to obtain proper authorization. You say that the doctor should not be penalized, and the claim
should be considered for payment. The Plan denied your request. The Plan says this provider is not a network
provider with the Plan and the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on October 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.

You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of Keytruda has not been demonstrated for the enrollee's condition.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Keytruda. Our reviewer says that Keytruda is not medically reasonable and necessary for the enrollee. The enrollee has a poorly differentiated neoplasm of unknown etiology, 90% probability meningioma (has a history of progressive lesions and neurologic manifestations) and 6% mesothelioma. No actionable mutations were found and no microsatellite instability was demonstrated upon Guardant 360 testing. The Medicare approved cancer compendia do not support the use of the requested medication in the clinical scenario. No articles from Medicare approved cancer journals were submitted in support of this request. Our physician reviewer found that the enrollee's condition does not meet criteria for Keytruda.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an IRF admission is
not medically necessary.

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 based on the documentation provided, the health Plan's denial should be upheld. You
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a
lower level of care (ex. skilled nursing facility/sub-acute rehab).

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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from November 11, 2020, to November 30, 2020.

You asked the Plan to pay for pneumatic compression device. You say that this device was medically necessary. The Plan denied your request. The Plan says this pneumatic compression device is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a PCD coded as E0675 is not covered by Medicare. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from November 11, 2020, to November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth #10.

You asked the Plan to pre-approve a crown. You say that the service is medically necessary. The Plan denied your request. The Plan says you have met frequency limits for this service and therefore it is 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. The Plan covers crowns once per tooth every 5 years.

We looked at the file and Medicare rules. The Plan previously covered a crown for tooth #10 on June 5, 2020. Based on this information, we decided that the Plan's rules for coverage of a crown for tooth #10 have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain/ceramic (D2740) for tooth #10.
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 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 October 23, 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 November 5, 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 November 5,
2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285) provided on September 20,
2020.

You asked the Plan to pay for an emergency room visit. You say that this was billed correctly. The Plan denied
your request. The Plan says 99284 is more appropriate in this case.

The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect
the services provided.

In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the
evaluation and management of a patient which requires three components (taking into account the urgency of
the clinical condition or the patient's mental status):

1. a comprehensive history;
2. a comprehensive examination; and
3. medical decision making of high complexity.

In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function. 

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 an emergency room visit Our reviewer says that the records do not support CPT 99285. Our reviewer found the patient did not appear to be exhibiting signs, symptoms, or test results suggestive of a severe life-threatening clinical condition to meet the criteria for code 99285. 

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 emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99285) provided on September 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on October 20, 2020.

You asked the Plan to pay for a pneumatic compression device. You say that the requested item is a necessity for the enrollee's care. The Plan denied your request. The Plan says the requested item is not covered by Medicare.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.

This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on October 20, 2020.