Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spinal surgery (CPT code(s): 22842, 22614, 22600,
63045, 63048), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your
request. The Plan says there are no current imaging studies to show the medical necessity of the requested
surgery.

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 surgery. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found criteria for additional cervical fusion surgery not met. There is no documentation of recent and
adequate physical therapy (PT). There is no documentation of a recent magnetic resonance imaging (MRI) or
computed tomography (CT) imaging study.

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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve the spinal surgery (CPT code(s): 22842, 22614, 22600, 63045, 63048), for the enrollee.
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 May 27, 2020, billed with codes 97032, 97016, three line items of J3490, J3411, and J3415.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device as billed. 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 procedures should be reported with the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes that describe the services performed. 

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.

We find that HCPCS/CPT codes 97016 and 97032 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.

Lastly, the drugs reported are considered a compounded medication which are correctly reported with a unit of the "compounded drug, not otherwise classified code. Reporting each component is not appropriate for this situation. 

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device as billed 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 May 27, 2020, billed with codes 97032, 97016, three line items of J3490, J3411, and J3415.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition, endoskeletal system, above knee, flexible protective outer surface covering system (L5964) and Lithium Ion battery charger, replacement only (L7368).

You asked the Plan to pre-approve the additional protective outer surface covering system and lithium battery charger. You say that the enrollee has demonstrated that she has both the capacity and the potential to function at a K3 level. Therefore, your denial of the L codes associated with the microprocessor knee and energy storing foot must be overturned. The Plan denied your request. The Plan says these items are not covered due to not being medically necessary or is included in the payment of the base item.

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 additional protective outer surface covering system and lithium battery charger. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found L5964 is not medically necessary as the documentation does not reveal that the patient has special needs for protection against unusually harsh environmental situations. 

We have confirmed that code L7368 has a bundled relationship with the base item and cannot be paid as billed. This code cannot be paid as a separate line item. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional protective outer surface covering system and lithium battery charger have not been met. Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal system, above knee, flexible protective outer surface covering system (L5964) and Lithium Ion battery charger, replacement only (L7368).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided November 11, 2020.

You asked the Plan to pay for the orthosis. You say that please see attached documentation that meets all criteria for L06500 to process claim for payment. The Plan denied your request. The Plan says the enrollee stated she received an unsolicted phone call offering free braces and she declined the offers. There is no documentation of the deliver. The enrollee also stated she never received a back brace.

Medicare has specific coverage criteria for each type of orthosis. Based on the records provided, the enrollee did not meet the criteria needed for the orthoses provided. The Plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the item at issue. As such, no payment may be made for this item. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there have been no documented changes to oral anti-diabetic medications, or to the diabetes treatment plan in the last 3-4 months.

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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the office notes do not document insulin use. The criteria are not met. 

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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 further home health physical therapy visits.
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 two visits are approved and 12 further are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain his level of function and/or prevent deterioration. The only provided records are a hospital history and physical and one follow-up progress note describing hospital treatment for acute on chronic systolic and diastolic congestive heart failure. No physical therapy notes are included detailing any physical needs or treatments. The enrollee has already been approved for a total of 23 home health physical therapy visits; nothing in the provided records documents why these 23 visits are inadequate to meet the enrollee's needs. 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 12 further home health physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasounds provided on December 29, 2020.

You asked the Plan to waive the copayment for the ultrasounds. You say that this was a medically necessary procedure you've had done for a number of years. You say that you were previously charged less, and the explanation of benefits states you aren't responsible for the payment. The Plan denied your request. The Plan says the copayments applied correctly.

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 $125 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility.

You have been asked to pay $119.07 for each ultrasound. The total amount you owe is $238.14 ($119.07/ ultrasound x 2 ultrasounds = $238.14). The ultrasounds fall within the "Outpatient Diagnostic Tests and Therapeutic Services and 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 ultrasounds provided on December 29, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the colonoscopy provided on January 25, 2021.
You asked the Plan to waive the copayment for the colonoscopy. You say that this was billed incorrectly as a diagnostic colonoscopy. You say that you were informed that pre-authorization was not needed, and it would be a $0 copayment. The Plan denied your request. The Plan says that the copayment applied correctly.
The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules also say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is no coinsurance, copayment, or deductible for a Medicare-covered colorectal cancer screening exam. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. A diagnostic colonoscopy was billed but the diagnosis code on the claim is for an encounter for a screening. Also, there were no medical records submitted to support the billing of a diagnostic colonoscopy. This means that the records do not support that a diagnostic colonoscopy was performed. The Plan says you must pay a $400 copayment for the colonoscopy. However, you cannot be asked to pay more than a $0 copayment for the colonoscopy. Therefore, we decided that the Plan has to waive the copayment for the colonoscopy provided on January 25, 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myobloc.

You asked the Plan to pre-approve Myobloc. You say that the requested Myobloc is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Dysport or Xeomin first.

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 Myobloc. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has sialorrhea. The requested drug is a new start. The preferred agent Dysport is not approved by the Food and Drug Administration or considered to have a medically accepted indication as defined by Medicare rules for the noted indication. Therefore, a trial of Dysport is not required. The preferred agent Xeomin approved by the Food and Drug Administration for the noted indication. The enrollee has not tried and failed Xeomin. The prescriber as not provided a sufficient medical rationale why this preferred agent is not appropriate for the enrollee. The elements of the coverage rule are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Myobloc have not been met. Therefore, we decided that the Plan does not have to pre-approve Myobloc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received January 19, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you were required to receive the comprehensive evaluation because you switched to a new dentist. The Plan denied your request. The Plan says the comprehensive evaluation benefit is limited to one procedure every three 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services have been exhausted. The Plan submitted evidence that you received a comprehensive oral evaluation on October 21, 2020. You were not eligible to receive a comprehensive oral evaluation on January 19, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) received January 19, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided to the enrollee on January 14, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you are appealing the enrollee's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the enrollee's 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that the enrollee received emergency care on January 14, 2021. The enrollee was asked to pay a $90 copayment for the emergency care. The enrollee's 2021 EOC states that enrollees must pay a $90 copayment for emergency care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided to the enrollee on January 14, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to waive the copayment for the skilled nursing facility (SNF) care provided from December 1, 2020 to December 10, 2020.

You asked the Plan to waive the copayment for the SNF care. You say that you are unable to pay for these services. The Plan denied your request. The Plan says that that the copayment was applied as per your plan benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $0 copayment per day, days 1 to 20 of SNF care. 

The Plan says you must pay $356 copayment for the SNF care. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for the SNF care. Therefore, we decided that the Plan has to waive the copayment for the skilled nursing facility (SNF) care provided from December 1, 2020 to December 10, 2020.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient visit (99203) provided on January 6, 2021.

You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration for the denied charges. The Plan denied your request. The Plan says only manual manipulation of the spine to correct subluxation is covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient visit (99203) provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services (CPT code 99214) provided on February 8, 2021, by an out-of-network provider.

You asked the Plan to pay for the office services. You say that you have a referral for the provider. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 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 office services (CPT code 99214) provided on February 8, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3D mammogram (77066) Diagnostic digital breast tomosynthesis (G0279) provided January 18, 2021.

You asked the Plan to pay for the diagnostic services. You say that you were charged patient responsibility of $119.81 for the mammogram that should have been $0 copay for breast cancer screening-mammogram per Medicare and the plan. The Plan denied your request. The Plan says the enrollee has not met the $390 deductible and the claim processed correctly per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $390 combined deductible.

The item or service you asked the Plan to pay for falls within the benefit category Outpatient diagnostic tests, therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $390 combined deductible. This is the amount you have to pay out of pocket before the plan will pay their share of covered medical services. This cost sharing is a contractual obligation that had not been met at the time the diagnostic services was received on January 18, 2021. Therefore, we decided that the Plan does not have to pay for the 3D mammogram (77066) Diagnostic digital breast tomosynthesis (G0279) provided January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on March 2, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that the treatment received was medically necessary. You have attached the medical records for the date of service. You are requesting the plan review the documents and process the claim towards payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 subsequent nursing facility care (99309) provided on March 2, 2021 by an out of network (OON) provider.