Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on January 25, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were referred to several other providers, and were sent back to the first dentist, which is why you received 3 examinations. The Plan denied your request. The Plan says you have exceeded the frequency limits set in the subscriber agreement.

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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on January 7, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on January 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) brain, including brain stem (70551) provided December 28, 2020.

You asked the Plan to waive the copayment for the MRI. You say that you don't think you should be responsible for this $100 copay because you full filled your deductible and did not think you would have to pay anything else that year. 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 $100 copayment after the deductible is met for each advanced imaging service.

You have been asked to pay $100 copayment for the MRI. The MRI falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) brain, including brain stem (70551) provided December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays
(D0274), and prophylaxis (D1110) provided on January 14, 2021 by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation, bitewing x-rays, and prophylaxis. You say
that you would like these services to be covered. The Plan denied your request. The Plan says the total amount
of $123.00 applied correctly as member liability. The Plan also says that cost sharing is a contractual obligation
under the Plan and cannot be waived.

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, you are responsible for the difference
between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), and prophylaxis (D1110) provided on January 14, 2021 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection rendered on January 5,
2021.

You asked the Plan to waive the coinsurance for these services. You say that you were not aware there would
be a cost for medications. The Plan denied your request. The Plan says the coinsurance 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 20%
coinsurance for Medicare Part B non-chemotherapy prescription drugs.

Review of the file shows that you received a Prolia injection on January 5, 2021. You have been asked to pay a
20% coinsurance for these services. These services fall within the Medicare Part B non-chemotherapy
prescription drugs 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 coinsurance for the Prolia injection
rendered on January 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the destruction by neurolytic agent; other peripheral
nerve or branch (genicular nerve radiofrequency ablation, left knee) for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that this service is still being studied for efficacy in the treatment of
knee pain due to osteoarthritis or in the setting of replacing or significantly deferring total knee arthroplasty.

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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. This is considered an
experimental/investigational procedure because it is the subject of on-going clinical trials. Our physician
reviewer found that the enrollee's condition does not meet criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the destruction by neurolytic agent; other peripheral nerve or branch (genicular nerve
radiofrequency ablation, left knee) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L1833, L2397, L2810, L0650) provided to the enrollee on September 17, 2020.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is evidence of misrepresented services.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. A physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for the back orthosis might have been met. The documentation does not support that the lumbar-sacral orthosis is being prescribed for one or more of the covered indications in this case, as there is no documentation of a physical examination of the back. 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, and there is no objective documentation of joint laxity. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L1833, L2397, L2810, L0650) provided to the enrollee on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and evaluation (92014) provided on January 7, 2021, by an out of network (OON) provider.

You asked the Plan to pay for the eye exam. You say that you should not be responsible for the cost of the services. The Plan denied your request. The Plan says in Long Term Care scenarios the OON provider is responsible for obtaining prior authorization. Since prior authorization was not obtained and the services were not determined to be urgent or emergent, the services are not covered.

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 enrollee was not in a covered, authorized skilled nursing facility stay. 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 eye exam and evaluation (92014) provided on January 7, 2021, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. 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 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 complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for surgical treatment of a hip fracture after a fall. Medical conditions are stable. There are no
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The
enrollee does require physical and occupational therapy but there is no documented need for an intensive
rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a
reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.

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 IRF admission and services.
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 LTACH care is medically necessary. The
Plan denied your request. The Plan says rules for LTACH care have not been met.

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 There is no documentation provided necessitating admission to an LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate
for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an
inpatient basis.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.

You asked the Plan to pre-approve Ondansetron. You say that the enrollee needs to start this drug as soon as possible. The Plan denied your request. The Plan says this medication does not fall under the enrollee's Part B benefits.

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 Ondansetron.

Benefits for Ondansetron 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) received January 22, 2021.

You asked the Plan to pay for the incisional biopsy of oral tissue-soft. You say that the Plan should pay for this claim. The Plan denied your request. The Plan says your $3,000 benefit exhausted prior to this claim.

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 payment is in excess of that which is covered under this benefit. The Plan has submitted evidence that you exhausted your $3,000 benefit allowance prior to this date of service. You are responsible for any remaining charges after the $3,000 benefit allowance is exhausted. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) received January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 25, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises, therapeutic procedure, 1 or more areas, each 15 minutes (97110) provided January 11, 2021 to January 22, 2021.

You asked the Plan to pay for the therapeutic exercises. You say that you have been receiving services with this provider since 9/2020 and have had improvement. You think the visits in January should be covered for continuity of care. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises, therapeutic procedure, 1 or more areas, each 15 minutes (97110) provided January 11, 2021 to January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of impacted tooth (D7220) provided on January
20, 2021.
You asked the Plan to pay for the removal of impacted tooth. You say that you think this procedure was coded
incorrectly. The Plan denied your request. The Plan says this service is not covered under your 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
removal of impacted tooth (D7220) provided on January 20, 2021.
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 18, 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 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on December 4, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you did not receive any services on this date of service and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for X-rays. The medical records show that you received an ultrasound on December 4, 2020. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for an ultrasound. An ultrasound 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 an ultrasound provided on December 4, 2020.