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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 9, 2020.

You asked the Plan to pay for the dental services. You say that your regular dental office closed due to the pandemic. You say that you had to go to a different office. You say that you were given an appointment in December 2020. You also say that this was not within the period to use the $3,500 that you had. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.

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 and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for this service that you received on December 17, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on December 9, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the enrollee meets criteria for SNF admission. Our physician reviewer found based on the documentation provided, the enrollee does have documented skilled nursing needs, receiving all of her nutrition via enteral feeds. The enrollee does not have documented skilled therapy needs, having reached a plateau in function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for denosumab 1MG injection (CPT code J0897) provided on November 25, 2020.

You asked the Plan to waive the coinsurance for the injection. You say that you received pre-authorization for this service and were told it would be paid by the Plan. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.

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).

Review of the file show that you received a denosumab 1MG injection on November 25, 2020. You have been asked to pay 20% coinsurance of the allowed amount for the Medicare Part B drug. The allowed amount is $926.92. The total you owe is $185.38 ($926.92 x 20% = $185.38).

Your 2020 EOC states that enrollees must pay 20% coinsurance for Medicare Part B covered drugs. 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 denosumab 1MG injection (CPT code J0897) provided on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on September 2, 2020 by an out of network (OON) provider.

You asked the Plan to pay for practitioner visit. You say that your provider depends upon the facility to verify eligibility and obtain proper authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 a practitioner visit provided on September 2, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified maxillofacial prosthesis (D5999) provided on January 14, 2021.
You asked the Plan to pay for the facial prosthesis. You say that this was not a dental item and it was provided to treat your sleep apnea. You cannot use a continuous positive airway pressure (CPAP) machine, so this device is necessary. The Plan denied your request. The Plan says this prosthesis is not covered by the dental 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 requested item is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an unspecified maxillofacial prosthesis (D5999) provided on January 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography of an additional vessel provided on August 3, 2020 billed with code 75774.

You asked the Plan to pay for the angiography services as billed. You say that the services rendered were coded correctly. The Plan denied your request. The Plan says the documentation does not support the billing of this code.

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 75744 is Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure).

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 angiography services as billed. Our reviewer says that the documentation does not support the billing of this code. Our physician reviewer found the enrollee underwent arteriogram on August 3, 2020. The provided report does not document higher order cannulations within the same vascular tree family. The elements of the coverage criteria 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 the angiography services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the angiography of an additional vessel provided on August 3, 2020 billed with code 75774.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 5, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral or facial photographic images (D0350) and the cone beam CT capture and interpretation (D0367 x 2) provided on January 14, 2021.

You asked the Plan to pay for the dental services. You say that you went to this office because they were listed as in network. You say that advised that you only wanted services that would be covered by your insurance. You say that you were never advised that you would have to pay for the x-rays. You say that you are very upset with this bill. You also say that you are on a fixed income. The Plan denied your request. The Plan says oral or facial photographic image is not listed as a covered service. The Plan says that cone beam CT capture and interpretation is not listed as a covered service either. The Plan also says that you were advised when you called the Plan that not all x-rays are covered, and coverage would be code specific.

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 oral or facial photographic images (D0350) and the cone beam CT capture and interpretation (D0367 x 2) provided on January 14, 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 October 15, 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 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from August 12, 2020, through August 24, 2020.

You asked the Plan to pay for the physician's 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on August 5, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided from August 12, 2020, through August 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint nerve ablation.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the most recent diagnostic injection only helped the pain by 40%.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation does not support a history of at least two medically reasonable and
necessary diagnostic medial branch blocks, with each one providing. Furthermore, your symptoms are radicular
in nature, and the guidelines state that the criteria for facet joint interventions must include non-radicular axial
pain.

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 pre-approve facet joint nerve ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the preparation and provision of antigens (95165) provided
on September 4, 2020.

You asked the Plan to pay for the preparation and provision of antigens. You say that this is supported. The
Plan denied your request. The Plan says this is not documented in the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 95165 is not supported in the medical record. Specifically, records were not provided
for the billed date of service. Without this documentation, this code cannot be verified. Based on this
information, we decided that Medicare rules for coverage of the preparation and provision of antigens have not
been met. Therefore, we decided that the Plan does not have to pay for the preparation and provision of
antigens (95165) provided on September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the complete
series x-ray (D0210) provided on February 3, 2021.

You asked the Plan to pay for the dental services. You say that these services were performed out of medical
necessity following dental work that you had received earlier in the year. You say that these services were
never performed in 2019. You say that they were supposed to issue a refund for the services but did not. The
Plan denied your request. The Plan says 1 comprehensive oral evaluation or periodontic evaluation is covered
every 3 years. The Plan says that 1 panoramic x-ray or complete series x-ray every 5 years. The Plan says that
the frequency limits for these services have been exceeded. The Plan also says that the claim for November 18,
2019 was processed correctly.

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 and the services are listed as covered,
the frequency limits have been exceeded. The record shows that the Plan paid for these services that you
received on November 18, 2019. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation (D0150) and the complete series x-ray (D0210) provided on February 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the left knee (73721).
You asked the Plan to pre-approve a knee MRI. You say that the enrollee has chronic knee pain. The Plan denied your request. The Plan says the enrollee has not tried conservative treatment.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 a knee MRI. Our reviewer says that the requested MRI is not medically necessary at this time. Our physician reviewer found the records show that the enrollee dislocated his knee fifty years ago and has progressive knee pain A plain film does not reveal new findings. The submitted medical records do not indicate the presence of instability or laxity and no treatments have been attempted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the left knee (73721).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377, K0108).

You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

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 additional accessories. Our reviewer says that the requested additional accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a request for headrest hardware (K0108). The approved E0955 headrest includes fixed hardware; therefore, the separate request for hardware exceeds the enrollee's medical need. The moldable forearm support (K0108) and the contoured hand pad (K0108) exceed the enrollee's medical need as the enrollee was approved for an arm trough (E2209). The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the right upper extremity with the ability to feed himself indicates that the enrollee can control any power options through their own individual switches.

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 additional accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377, K0108).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a tissue transfer (14060) provided on October 7, 2020.
You asked the Plan to pay for a tissue transfer. You say that this should be covered. The Plan denied your
request. The Plan says the documentation is not sufficient to support this code.
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 14060 is adjacent tissue transfer or rearrangement,
eyelids, nose, ears and/or lips; defect 10 sq cm or less.
We find that CPT code 14060 is not supported in the medical record. Specifically, the submitted medical
records do not document what body part this procedure was performed on. Without this information, this code
cannot be verified. Based on this information, we decided that Medicare rules for coverage of a tissue transfer
have not been met. Therefore, we decided that the Plan does not have to pay for a tissue transfer (14060)
provided on October 7, 2020.