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 November 2, 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 2,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310), the periapical x-rays (D0220 x 2), the root canal (D3330), and the cone beam CT capture with interpretation (D0367) provided from October 30, 2020, to November 19, 2020.
You asked the Plan to pay for the dental services. You say that this provider is listed as in network. You also say that the dentist's office advised that they were not in network with your plan. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network 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, dental services performed out of
network are not covered. Additionally, regardless of the provider's network status the dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310), the periapical x-rays (D0220 x 2), the root canal (D3330), and the
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 standard POV (K0806).
You asked the Plan to pre-approve a Group 2 standard POV. You say that the requested item is necessary for your care. The Plan denied your request. The Plan says the requested POV is not reasonable and necessary.
The Plan follows Medicare rules. Medicare rules say that a Group 2 POV is not reasonable and necessary. The request is for a Group 2 POV. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard POV (K0806).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a second inpatient admission provided from December 30,
2020, to January 7, 2021.

You asked the Plan to pay for a second inpatient admission. You say that this was medically necessary and that
the admissions were unrelated. The Plan denied your request. The Plan says this cannot be paid separately from
the first admission.

The Plan follows Medicare rules. Medicare rules say that when a patient is discharged/transferred from an
acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital
on the same day for symptoms related to, or for evaluation and management of, the prior stay's medical
condition, hospitals shall adjust the original claim generated by the original stay by combining the original and
subsequent stay onto a single claim.

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 a second inpatient admission. Our reviewer
says that the criteria for coverage of a second admission have not been met. Our physician reviewer found the
records show that the enrollee was originally admitted to the hospital from December 19, 2020, to December
30, 2020. On the day of discharge, the patient had returned to baseline oxygen requirements and appeared
stable. He was discharged home with his son and was ordered home physical therapy. He was admitted again
hours later the same day due to being very weak and unable to get out of his chair. He had declined to go to an
inpatient rehabilitation prior to discharge and later agreed to attend. Based on the provided documentation, the
second admission to the hospital appeared directly related to the first admission. The enrollee needed more
intensive and rehabilitation. The discharge home was not appropriate for his level of function and degree of
recovery.

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 second inpatient admission have not been met. Therefore, we decided that the
Plan does not have to pay for a second inpatient admission provided from December 30, 2020, to January 7,
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI), lower extremity other than joint

You asked the Plan to pre-approve magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences (73720). You say that the enrollee needs an MRI. The Plan denied your request. The Plan says medical records do not show the enrollee has tried standard treatment first.

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 magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences (73720). Our reviewer says that the MRI is not medically necessary. Our physician reviewer found the records provided do not show that the patient had failed conservative treatments, for her nonspecific complaints, such as physical therapy. There were no clear signs of a red flag diagnosis which might warrant more immediate use of MRI testing. Therefore, this request for MRI will be considered not medically necessary 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 magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences (73720) have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI), lower extremity other than joint
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee requires intensive strengthening and retraining as a result of physical deconditioning from her hospital admission. You say that the enrollee is at high risk to fall and further injure herself due to decreased mobility, poor balance change in mental status, and pain. You say that an IRF is the recommended level of care by CMS for the enrollee's medical conditions. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive the care needed in another setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treatment of a hip fracture and non-surgical management of a wrist fracture after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says a lower level of care might be appropriate.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for aneurysm of the mesenteric artery, sepsis and respiratory failure. Medical problems are stable.
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. While the medical record supports a need for physical and/or occupational therapy, there is no
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different
level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and
benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, two first intraoral periapical x-rays, bitewing x-rays, adjunctive procedure, prophylaxis, problem focused limited oral evaluation, and extraction provided on November 16, 2020, and November 30, 2020.
You asked the Plan to pay for the dental services. You say that you would like to be reimbursed for these services. The Plan denied your request. The Plan says the treating provider has opted out of Medicare. 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, two first intraoral periapical x-rays, bitewing x-rays, adjunctive procedure, prophylaxis, problem focused limited oral evaluation, and extraction provided on November 16, 2020, and November 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network
provider.
You asked the Plan to pre-approve physical therapy to be provided by the requested out-of-network provider.
The Plan denied your request. The Plan says in most cases, care you receive from an out-of-network provider
(a provider who is not part of our plan's network) will not be covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical
therapy to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for wound debridement provided by an out-of-network provider on September 28, 2020.
You asked the Plan to pay for the wound debridement. You say that the documentation outlines the medical necessity of the service and the claim should be paid. The Plan denied your request. The Plan says in-network providers were available.
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 wound debridement provided by an out-of-network provider on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on November 3, 2020.
You asked the Plan to pay for the crown. You say that you believe this service should be covered. The Plan denied your request. The Plan says your annual maximum benefit has been exhausted.
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 Plan offers a $1,500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on October 15, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the crown (D2740) provided on November 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission provided from October 27, 2020, to October 28, 2020.

You asked the Plan to waive the copayment for the inpatient admission. You say that you are not responsible for the copayment because you were advised that anything Covid-related was covered. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment per day for days 1-7.

You have been asked to pay a $225 copayment for the inpatient admission. The inpatient admission falls within the "Inpatient hospital care" 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 inpatient admission provided from October 27, 2020, to October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from August 9, 2019, and October 3, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the services was not filed until December 17, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided from August 9, 2019, and October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 17, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor kit.

You asked the Plan to pre-approve a Freestyle Libre 14-day sensor kit. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day. Based on this information, we decided that Medicare rules for
coverage of a Freestyle Libre 14-day sensor kit have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Freestyle Libre 14-day sensor kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6532.

You asked the Plan to pre-approve the compression stockings. You say that you believe that the stockings should be covered. It is written medically necessary for optimal fit by your therapist and doctor. The Plan denied your request. The Plan says the stockings/wraps do not meet the definition of a surgical dressing, as there is no qualifying wound.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6532 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6532.