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

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a complete
intraoral series of radiographic images (D0210) provided on February 5, 2020.

You asked the Plan to pay for a comprehensive oral evaluation, and a complete intraoral series of radiographic
images. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says
the services are a covered benefit, but you have exceeded the frequency limit of one every 3 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 comprehensive oral evaluation, and a complete intraoral series of radiographic images have not
been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on
January 21, 2019. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation
(D0150), and a complete intraoral series of radiographic images (D0210) provided on February 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that you are not able to walk by yourself. The Plan denied your request. The Plan says you do not need the skills of a therapist daily.

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 physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a standby assist to contact guard assist level with functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 

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 a skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator and the portable oxygen provided on January 2, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the oxygen concentrator and the portable oxygen. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

The requested provider in this case is not a network provider with the Plan. 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 oxygen concentrator and the portable oxygen provided on January 2, 2021 by an out of network (OON) provider.
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 3, 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 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for a psychotherapy visit on January 4, 2021.

You asked the Plan to pay for a psychotherapy visit. You say that the requested services are a covered benefit with 30% coinsurance. The Plan denied your request. The Plan says that rules for out of network care have not been met.

The Plan must follow Medicare rules. Medicare rules say that PPO plans must provide reimbursement for all Plan-covered medically necessary services received from non-contracted providers without prior authorization requirements. 

We looked at the file and Medicare rules. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding the medical necessity of the services at issue. Based on this information, we decided that Medicare rules for coverage of a psychotherapy visit have been met. Therefore, we decided that the Plan has to pay for a psychotherapy visit on January 4, 2021.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.

You asked the Plan to pre-approve Durolane. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 Durolane. Our reviewer says that the
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer
found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has tried
and failed Orthovisc and Monovisc. There is no documentation provided indicating that the Plan's required
drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee
does not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have
to pre-approve Durolane.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve subacromial decompression/acromioplasty.

You asked the Plan to pre-approve subacromial decompression/acromioplasty. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 subacromial decompression/acromioplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are still having nighttime pain. There is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. The configuration of the acromium has not been delineated in
detail. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, you do not meet criteria for the requested 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 subacromial decompression/acromioplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve subacromial decompression/acromioplasty.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an injection into the spine provided on January 25, 2021.

You asked the Plan to waive the co-payment for an injection into the spine. You say that you receive these injections every two months, and you thought a $45 co-payment would apply for this visit. The Plan denied your request. The Plan says the co-payment you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 co-payment for outpatient hospital services.

You have been asked to pay a $290 co-payment for an injection into the spine. The records show that you pay a $290 co-payment when these services are received in an outpatient hospital facility. The records also show that these services were rendered in an outpatient hospital facility. 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 co-payment for an injection of anesthetic and/or steroid drug into the spine (64483) at an outpatient hospital facility provided on January 25, 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

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
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 November 3, 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 November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3330).

You asked the Plan to pre-approve the endodontic therapy. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 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 pre-approve endodontic therapy (D3330).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upgraded electronics, electronic connection to 2 or more power options (E2311) expandable controller (E2377) and harness (E2313).

You asked the Plan to pre-approve the upgraded electronics. You say that Please reconsider the original documentation and additional information provided for this K0861 and components needed to meet her current medical needs. The Plan denied your request. The Plan says the upgraded electronics I expandable controller, harness and electronic connector to 2 power options) are 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 upgraded electronics. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the LCD criteria for the requested upgraded electronics for the power wheelchair. The records indicate she is able to feed herself and groom herself with supervision/set-up assistance. Her left upper extremity strength is reported to be within functional limits and her right upper extremity strength is 3-/5. Records indicate her upper extremity strength and function are adequate for her to be able to control the power options using their own 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 upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve upgraded electronics, electronic connection to 2 or more power options (E2311) expandable controller (E2377) and harness (E2313).