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 August 20, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.
We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 14, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code G0483 is not supported.

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 G0483 is definitive drug testing, 22 or more classes.

We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation of definitive drug testing of 22 or more classes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear provided on January 30, 2021.
You asked the Plan to pay for the eyewear. You say that The Plan denied your request. The Plan says the enrollee did not have coverage for routine eyewear.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine eyewear. The services you asked the Plan to pay for are considered routine eyewear. Therefore, we decided that the Plan does not have to pay for eyewear provided on January 30, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on July 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal.
The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab work provided on July 8, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits.
You asked the Plan to pre-approve additional PT visits. The Plan denied your request. The Plan says eight (8)
additional PT visits as not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 eight (8) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally
accepted as specific and effective therapy for the enrollee's high functional level beyond what was approved by
the health Plan. The enrollee has had prior therapy for this condition and the records do not demonstrate that
the unique skills of a professional therapist are required to safely and effectively provide treatment, that the
services can be safely and effectively performed only by a therapist, or by or under the supervision of a
therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a
maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of eight (8) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns provided on March 18, 2021.
You asked the Plan to pay for the crowns. You say that you thought these services would be fully covered. The
Plan denied your request. The Plan says your annual maximum benefit has been exhausted.
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 Plan offers a $1,000 annual dental
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are
responsible for the full charges of any additional dental services. The record shows that you met the annual
maximum benefit while processing this claim for the March 18, 2021, date of service and your annual
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the two
crowns provided on March 18, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Hyalgan (J7321).
You asked the Plan to pre-approve Hyalgan. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules have not been met because Orthovisc and Monovisc have not been tried.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Hyalgan. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that the provided records indicate that the requested drug is a new start. The record does not indicate that the enrollee has tried and failed, or has a contraindication to, the Plan's preferred step-one agents. The elements of the coverage rule are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Hyalgan (J7321).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on June 16, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 31276 and 31255 are not supported.
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 31276 is nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed. The definition of code 31255 is nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior). We find that CPT codes 31276 and 31255 are not supported in the medical record. Specifically, there is no documentation of a surgical nasal/sinus endoscopy with frontal sinus exploration to support code 31276.
There is no documentation of a surgical nasal/sinus endoscopy with total ethmoidectomy to support code 31255. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported porcelain fused to metal crown provided on November 23, 2020.
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain fused to metal crown. You say that you would like to appeal these services. The Plan denied your request. The Plan says you have met your annual maximum 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 Plan offers a $2,000 allowance for covered dental services. The contract says that if the total covered cost for dental services is more than $2,000 or if you exceed a service limit, you are required to pay the difference. The record shows that you met the
annual maximum benefit on the June 30, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported porcelain fused to metal crown provided on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5254LT, V5254RT) received February 1, 2021 from the out-of-network supplier.
You asked the Plan to pay for the hearing aids. You say that you have always been able to use an out-of-network supplier for your hearing aids. The Plan denied your request. The Plan says your contract states you must use a network supplier for your hearing aid purchase.
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 purchased through a Plan network supplier. We looked at the file, and the Plan's rules. The Plan contract states that you must select a device from the covered list available through the Plan's participating hearing aid supplier. 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 (V5254LT, V5254RT) received February 1, 2021 from the out-of-network supplier.
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 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 October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 26, 2021.

You asked the Plan to waive the copayment for urgent care visit. You say that you do not feel the enrollee should have to pay this amount because of her coverage. The Plan denied your request. The Plan says the copayment amount the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay $65 copayment for urgent care visit. 

The enrollee has been asked to pay $65 copayment for urgent care visit. Urgent care visit falls within the Urgently Needed Services 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 copayment for an urgent care visit provided on January 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.

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 enrollee was admitted due to an infected heel ulcer while at home recovering
from back surgery. The enrollee continues to receive acute care services, and these have not been denied. The
medical record does not indicate that the enrollee requires services that the enrollee is not currently receiving
but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The
requested service cannot be recommended.

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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hysteroscopy outpatient surgery (58558) provided on February 15, 2021.

You asked the Plan to waive the copayment for a hysteroscopy outpatient surgery. You say that you had the same procedure done in January and paid the copayment. You also say that you should not have to pay another copayment for February's procedure. 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 $150 copayment for outpatient hospital services. 

You have been asked to pay a $150 copayment for a hysteroscopy outpatient surgery. The EOC confirms that $150 is the required copayment for this service. Hysteroscopy outpatient surgery falls within the outpatient hospital services 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 a hysteroscopy outpatient surgery (58558) provided on February 15, 2021. 

Your complaint about the Plan's processing of your copayment obligation is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional eight (8) PT visits.
You asked the Plan to pre-approve an additional eight (8) PT visits. You say that the patient continues with physical therapy post right total knee arthroplasty and she reports resting better and no longer interrupted due to pain. The Plan denied your request. The Plan says eight (8) additional PT visits are not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 additional eight (8) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate significant deficits that require ongoing skilled therapy. The records do not show that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. Currently, the enrollee is independent without difficulty for activities of daily living and is independent with ambulation without the use of an assist device. She is able to walk for up to an hour each day. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 additional eight (8) PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional eight (8) PT visits.