Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the irrigation of implanted venous access device for drug delivery systems (96523) provided November 23, 2020.
You asked the Plan to waive the cost share for the irrigation of implanted venous access device for drug delivery systems. You say that you would like this cost share waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 $40 copayment for physician/practitioner services, including doctor's office visits.
You have been asked to pay a total cost share of $28.65 for the irrigation of implanted venous access device for drug delivery systems which is less than the $40 required copayment. This service 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 irrigation of implanted venous access device for drug delivery systems (96523) provided November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic subcutaneous injections (1x 96372-XS, 4x96372-76-XS), vasopneumatic device therapy (97016), and unclassified drugs (4xJ3490-51-59) provided on July 21, 2021 during treatment with the Sanexas device.
You asked the Plan to pay for the medical services as billed. You say that this is medically necessary treatment which should be paid in full. The Plan denied your request. The Plan says the denied codes represent services that are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly and used the proper codes.
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 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. We find that CPT code 97016 is 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. Payment for codes 96372 and J3490 is also 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. Therefore, we decided that the Plan does not have to pay for the therapeutic subcutaneous injections (1x 96372-XS, 4x96372-76-XS), vasopneumatic device therapy (97016), and unclassified drugs (4xJ3490-51-59) provided on July 21, 2021 during treatment with the Sanexas device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan of the brain for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show the results from a detailed nervous system exam.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has memory loss for several year duration. The documentation provided only includes record since March 2021. One SLUMS score of 22 is noted in July 2021. A cognitive decline over a six-month period is not formally documented in the provided records. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan of the brain for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer device.
You asked the Plan to pre-approve the Superion interspinous spacer device. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Superion interspinous spacer device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical 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 the Superion interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wrist hand orthosis (L3908) provided March 19, 2021.
You asked the Plan to waive the copayment for the orthosis. You say that the doctor's talked to you about getting a wrist brace and the nurse told you it would be at no cost because you have Medicare. If you knew there was going to be a cost, you wouldn't have received. The Plan denied your request. The Plan says this claim was processed with the correct cost share 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 20% coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. You have been asked to pay $12.35 ($61.78 x 20%) coinsurance for the orthosis. The provider billed the orthosis falls within the Durable medical equipment (DME) and related 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 the wrist hand orthosis (L3908) provided March 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor for the enrollee.
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of insulin use.
The Plan must follow Medicare rules. The rules say that a continuous glucose monitor is only covered for insulin users.
The records do not show that you currently use insulin. Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second diagnostic medial branch block (MBB) (64494, 64493).
You asked the Plan to pre-approve a second diagnostic MBB. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that a second diagnostic facet procedure is considered medically reasonable and necessary if, after the first diagnostic facet joint procedure, there is a consistent positive response of at least 80% relief of primary (index) pain. We looked at the file and Medicare rules. The submitted records do not show that the enrollee had at least 80% pain relief after the first MBB. Based on this information, we decided that Medicare rules for coverage of a second diagnostic MBB have not been met. Therefore, we decided that the Plan does not have to pre-approve a second diagnostic medial branch block (MBB) (64494, 64493).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the biopsy of bladder using an endoscope (52204) provided on March 10, 2021, by an out of network (OON) provider.
You asked the Plan to pay for the biopsy of bladder using an endoscope. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 the biopsy of bladder using an endoscope (52204)
provided on March 10, 2021, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair of power wheelchair accessories (K0108, K0019, K0739) for the enrollee.
You asked the Plan to pre-approve the repair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve repair of power wheelchair accessories (K0108, K0019, K0739) for the enrollee.
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 therapy is crucial for your health. The Plan denied your request. The Plan says you do not require intensive daily therapy.
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 physician reviewer found that you were admitted to the acute care hospital for syncope and a fall. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, and an intensive rehabilitation therapy program.
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device for the enrollee. You asked the Plan to pre-approve the device. You say that the doctor believes that this device is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is reported to be ambulatory with a left ankle foot orthosis, cane or walker and uses a wheelchair for community mobility. No further details of history, physical examination or recent evaluation and progress notes by a physician or any therapist. There is a prescription by a physician but no clinical documentation of her neurological status current or past to establish the medical necessity by the physician. There is limited clinical information and justification documented by the device manufacturer. Furthermore, it is doubtful that the enrollee will gain normal function of her left upper extremity as claimed after this many
years after her stroke. The requested device is not a standard of care for the diagnosis of stroke. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve swollen vein closure with laser energy for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there is evidence of significant arterial disease.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is well-documented significant peripheral artery disease. Coverage criteria requires that
there be an absence of significant peripheral artery disease.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve swollen vein closure with laser energy for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine PCR testing provided on August 26, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that PCR amplification techniques raise considerable concerns regarding contamination from one specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results may also be challenging. Amplification of organisms representing latent infection or colonization cannot be distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large groups of patients for many of the microorganisms. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine PCR testing provided on August 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is experimental/investigational.
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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is still considered experimental/investigational. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260) and other accessories.
You asked the Plan to pre-approve a semi-electric hospital bed and other accessories. You say that this equipment is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the documentation does not demonstrate you have a medical condition which requires positioning of the body in ways not achievable with an ordinary bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed and other accessories. Our reviewer says that the semi-electric hospital bed is not medically necessary and reasonable. Our physician reviewer found the documentation does not clearly reveal that your condition has failed positioning of the body in ways not feasible in an ordinary bed. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for this patient. Because the semi-electric bed is not medically necessary, the related accessories are not reasonable 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 a semi-electric hospital bed and other accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260) and other accessories.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need SNF care and treatment to get stronger. The Plan denied your request. The Plan says that you do not require complex daily nursing care that must be provided in a skilled nursing facility.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete root canal (D3332) provided on July 14, 2020.
You asked the Plan to pay for the dental service. You say that you went to get a root canal. You say that the root canal could not be done because your tooth was broken. You also say that you went to your regular dentist to have the tooth pulled. The Plan denied your request. The Plan says incomplete root canal is not listed as a covered service.
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 incomplete root canal (D3332) provided on July 14, 2020.