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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on
December 14, 2020.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you believe these
services should be covered. The Plan denied your request. The Plan says the treating provider opted out of
Medicare effective April 6, 2015, to April 6, 2021. The Plan also says that services performed by a privately
contracted provider are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
covered when they are received by a Medicare opt out provider. Therefore, we decided that the Plan does not
have to pay for the periodic oral evaluation and prophylaxis provided on December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the thorax.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there are no physical exam results that show why this study is needed.
The Plan must follow Medicare rules. Medicare rules say that CT 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 the most recent exam of 4/15/21 was compared to the most recent study of 4/20/20 and the left upper lobe nodule was considered stable and no new worrisome nodule was described. Since there is some discrepancy in the size of the left upper lobe nodule the most recent report describing stability is reassuring. Nonetheless a surveillance scan is still indicated based upon the reading of the 4/20/20 exam compared to the 2017 study. In an effort to provide adequate surveillance for this patient with known Cocci in the past a one year surveillance, ie 4/15/22 would be indicated but there is no justification offered in the submitted records to support a followup scan so soon after the 4/15/21 exam which described a stable 6mm left upper lobe nodule unchanged since 4/20/20. 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 CT scan of the thorax.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on September 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 services were not billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that procedure code 00731 (anesthesia) was not billed
with an appropriate diagnosis code. 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 anesthesia
services rendered on September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyperbaric Oxygen Therapy (G0277, 99183).
You asked the Plan to pre-approve Hyperbaric Oxygen Therapy. You say that the Hyperbaric Oxygen Therapy is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Hyperbaric Oxygen Therapy is covered when 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 Hyperbaric Oxygen Therapy. Our reviewer says that the Hyperbaric Oxygen Therapy is not medically necessary. Our physician reviewer found Hyperbaric Oxygen therapy is not medically necessary because the documentation does not support failure of conservative medical and surgical management for chronic osteomyelitis or a diabetic lower extremity wound. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyperbaric Oxygen Therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyperbaric Oxygen Therapy (G0277, 99183).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, five additional intraoral periapical x-rays, bitewing x-rays, and panoramic x-ray provided on January 4, 2021 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, intraoral periapical x-rays, bitewing x-rays, and panoramic x-ray. You say that you confirmed with the facility that they accepted your insurance. You also say that you feel you should not be held responsible. The Plan denied your request. The Plan says that these services were rendered by an OON provider, and are not covered because your healthcare plan does not have OON benefits. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits or provider eligibility.
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 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, five additional intraoral periapical x-rays, bitewing x-rays, and panoramic x-ray provided on January 4, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve a complete upper denture. You say that you need the broken denture replaced. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 5 Plan years.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete upper denture have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on June 6, 2018. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999), the scaling and root planing (D4341 x 4), the extractions (D7210 x 6), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223), and the therapeutic parenteral drug (D9612) provided on December 7, 2020.
You asked the Plan to pay for the dental services. You say that you were never informed by the Dental Plan that prior authorization was required in order to obtain these services. The Plan denied your request. The Plan says prior authorization was not obtained before the services were rendered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that [state physician reviewer's conclusion, e.g. "the service is not medically necessary." or "you need this medical item."] Our physician reviewer found [state the medical finding(s) upon which the physician based his/her conclusion] We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the unspecified preventive service (D1999), the scaling and root planing (D4341 x 4), the extractions (D7210 x 6), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223), and the therapeutic parenteral drug (D9612) provided on December 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continued SNF stay.You asked the Plan to pre-approvethe continued SNF stay. You say that the enrollee still requires physical therapy and occupational therapy services for a safe discharge home.The Plan denied your request. The Plan says SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from November 5, 2020, to April 7, 2021. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pre-approvea continued SNF stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown repair necessitated by restorative material failure (D2980 x 2), and the fixed partial denture (bridge) repair (D6980) provided on January 4, 2021.Youasked the Plan to pay forthe dental services. You say that you waited until January to have your dental work done so that you would not have to worry about the dentist's network status. You also say that your repairs did not include dentures as you do not even have dentures.The Plan denied your request. The Plan says crown repair necessitated by restorative material failure is no listed as a covered service. The Plan says that fixed partial denture (bridge) repair is not listed as a covered serviceeither. The Plan also says that you when you contacted them in November 2020, you were advised of your dental benefits.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 forthe crown repair necessitated by restorative material failure (D2980 x 2), and the fixed partial denture (bridge) repair (D6980) provided on January 4, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for an interstitial continuous glucose monitoring
system.
You asked the Plan to pre-approve Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial
continuous glucose monitoring system (A9276). You say that you need a CGM that works with your insulin
pump. The Plan denied your request. The Plan says the requested CGM is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that only a CGM that has been FDA approved is
eligible for coverage under Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose
monitoring system (A9276) have not been met. Therefore, we decided that the Plan does not have to preapprove
sensors for an interstitial continuous glucose monitoring system.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services (99285) provided on September 14, 2020.
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the billed service.
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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We asked our coder 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 emergency department services. Our reviewer says that CPT code 99285 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do not include sufficient documentation to support billing 99285 to the health plan, therefore this level of service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department services (99285) provided on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 29, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) neurosurgeon. You asked the Plan to pre-approve the OON neurosurgeon services. You say that you were given the names of in network neurologists. You say that this is not the type of provider the enrollee needs to see. You say that the enrollee is waiting too long for treatment of her symptoms. The Plan denied your request. The Plan says there are 32 neurosurgeons that are near the member who are in-network. The Plan says that this is not an urgent or emergent situation. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network neurosurgeons available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve OON care. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) neurosurgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not support that the required drugs would be contraindicated or less effective; therefore, Durolane is not reasonable or medically necessary. 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 Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on November 17, 2020.
You asked the Plan to pay for the provided device. You say that the device was intended to help prevent the onset of deep vein thrombosis. The Plan denied your request. The Plan says the service is not a covered benefit.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on November 17, 2020.