Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional physical therapy visits (CPT code
97164), for the enrollee.

You asked the Plan to pre-approve additional physical therapy visits. You say that the enrollee continues to
have limited strength which limits the enrollee's ability to perform stairs, ambulation of community safe speeds,
increased fall risks, according to outcome measures, and requires rolling walker for all functional mobility. The
Plan denied your request. The Plan says the additional visits are not 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 additional physical therapy visits. Our
physician reviewer found based on the medical records provided there is no documentation that the 6 denied
outpatient physical therapy visits meet the requirements listed in the LCD L33631 for Medicare coverage.
Records document that the enrollee's condition has improved with the twenty-one (21) therapy visits thus far
and the enrollee is without pain, has improved mobility and is ambulating community distances independently.
After completion of the four additional therapy visits that have been approved, utilization of the home exercise
program appears to be appropriate to further improve her strength.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve six (6) additional physical therapy visits (CPT code 97164), for the
enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yervoy and Opdivo for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is not being prescribed for a medically necessary indication.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has recurrent metastatic non-small cell lung cancer that has progressed on prior nivolumab. PD-L1 is less than 1%. Nivolumab in combination with ipilumumab is approved as 1st line treatment in patients with Pd-L1 more than 1%. The enrollee does not fit either criteria. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy and Opdivo for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient consultation and biopsy services provided on December 30, 2020 to December 31, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient consultation and biopsy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received by the enrollee are not a covered benefit when provided by an OON provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient consultation and biopsy services provided on December 30, 2020 to December 31, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EKG and a specialist office visit provided by a participating provider on January 4, 2021.

You asked the Plan to waive the copayment for an EKG and a specialist office visit. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayments have been applied.

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 $25 copayment and a $50 copayment for outpatient diagnostic tests/diagnostic test and physician/practitioner services/specialist.

You have been asked to pay $18.75 which is less than your copayment amount of $25 for an EKG and a $50 copayment for a specialist office visit. The total amount you are being asked to pay is $68.75 ($18.75 + $50 = $68.75). An EKG falls within the outpatient diagnostic tests/diagnostic test benefit category and a specialist office visit falls within the physician/practitioner services/specialist 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 an EKG and a specialist office visit provided by a participating provider on January 4, 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 October 8, 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 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on June 19, 2020.

You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says that it is important to know which providers are part of our network because, with limited exceptions, the enrollee must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.

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 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 a domiciliary, rest home visit provided on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a debridement of subcutaneous tissue (11042) performed on January 19, 2021.
You asked the Plan to waive the deductible for a debridement of subcutaneous tissue. You say that do not agree that you should be charged for such a simple service. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 a $750 deductible applicable to each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient hospital services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible applicable to each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. This cost sharing is a contractual obligation that had not been met at the time a debridement of subcutaneous tissue was received on January 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a debridement of subcutaneous tissue (11042) performed on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to high noble metal (D6750) and pontic - porcelain fused to high noble metal (D6240).

You asked the Plan to pre-approve a retainer crown and pontic. You say that these services are medically necessary due to your health conditions. The Plan denied your request. The Plan says these services are not covered under 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 pre-approve a retainer crown - porcelain fused to high noble metal (D6750) and pontic - porcelain fused to high noble metal (D6240).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept Procedure.

You asked the Plan to pre-approve the Intracept Procedure. You say that the member's pain is disabling, affects their quality of life on a daily basis and has been of long-term duration. The Plan denied your request. The Plan says this service is not medically necessary

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Intracept Procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is considered experimental and more research is needed to show its safety and efficacy.

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 Intracept Procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept Procedure.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ambulance transportation services provided on December 30, 2020.

You asked the Plan to waive the cost share for the ambulance services. You say that it was not your fault there were no beds available at the hospital. The Plan denied your request. The Plan says the claim processed correctly per plan benefits.

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 $200 copay per one-way trip for ambulance services.

You have been asked to pay a $200 copay for the ambulance services. The services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the ambulance transportation services provided on December 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on October 15, 2020.

You asked the Plan to pay for ambulance services. You say that the enrollee's last day of hospice was October
14, 2020. The Plan denied your request. The Plan says the denial of payment for these services is correct,
because the enrollee was enrolled in a hospice program until October 14, 2020 so the Plan is not responsible for
coverage of services until the first day of the following month.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on October 14, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services
provided on October 15, 2020.
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 September 25, 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 September 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laparoscopy (44204) and colpopexy (57282).

You asked the Plan to pre-approve the surgical services. You say that you would like reconsideration because this procedure is medically necessary in order to live a normal and full life. The Plan denied your request. The Plan says this procedure is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgical services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provided are over eight years old. The medical records are insufficient to establish the medical necessity and reasonableness of the requested service as defined by Medicare rules. The elements of the coverage rule are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pre-approve the laparoscopy (44204) and colpopexy (57282).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a POV (CPT code K0800) to be provided by an out-of-network
provider.

You asked the Plan to pre-approve the POV. You say that you had a stroke and are unable to get around as you
need. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the POV have not been met. Your medical information confirms
that you have not had the required face-to-face encounter, a prescription with the seven (7) required elements,
or an in-home assessment. Therefore, we decided that the Plan does not have to pre-approve a POV (CPT code
K0800) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on September 9, 2020 by an out of network provider.

You asked the Plan to pay for the podiatry services. You say that the enrollee misled you with incorrect insurance information. The Plan denied your request. The Plan says you did not request prior authorization.

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 service 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 podiatry services provided on September 9, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on August 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 services provided on August 17, 2020 by an out of network (OON) provider.