Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 23, 2020.

You asked the Plan to pay for the orthosis. You say that as per CMS, documentation of a physical examination is not required during the pandemic. Please review the provided documentation and process the claim for payment as the enrollee is using the item and it is helping the enrollee. The Plan denied your request. The Plan says the supporting documentation does not match the information sent on the claim. The services are not documented in the enrollee's medical records.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We find that CPT code L0650 is not supported. Specifically, the plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the 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 September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on January 12, 2021.

You asked the Plan to pay for the shingles vaccine. The Plan denied your request. The Plan says this is not a
covered vaccine.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine.
The Plan follows the same rules.

The records do not show that you have been injured or directly exposed to any illness related to the shingles
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on
January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have waive the copayment for alginate or other fiber gelling dressing, wound cover, sterile (A6197) sterile water/saline, 500 ml (A4217) gauze, non-impregnated, non-sterile, without adhesive border (A6216) non-waterproof tape (A45450) provided August 6, 2020.

You asked the Plan waive the copayment for the medical supplies. You say that you are being billed for medical supplies you did not receive. They have turned you over to collections and you feel you should not be responsible. The Plan denied your request. The Plan says the correct cost share was applied per the Evidence of Coverage.

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 20% coinsurance for Durable medical equipment (DME) and related supplies.

You have been asked to pay $82.15 ($410.76 x 20%) for the medical supplies. The medical supplies fall within the Durable medical equipment (DME) and related 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 waive the copayment for alginate or other fiber gelling dressing, wound cover, sterile (A6197) sterile water/saline, 500 ml (A4217) gauze, non-impregnated, non-sterile, without adhesive border (A6216) non-waterproof tape (A45450) provided August 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy session, 60 minutes (90837) provided on November 12, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that the enclosed medical records clearly reflect the medical necessity for the services rendered. Please process the enclosed documents at the earliest and reprocess the claim for 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 individual psychotherapy session, 60 minutes (90837) provided on November 12, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on September 8, 2020.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was 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 $200 copayment per visit for each in-network outpatient surgery, including services provided at hospital outpatient facilities.

Review of the file shows that you received outpatient surgical services on September 8, 2020. Per the contract with the Plan, there is a $200 copayment per visit for each in-network outpatient surgery, including services provided at hospital outpatient facilities. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $50.53. Given that the allowed amount was less than the $200 copayment, you have been asked to pay $50.53 for these services.

Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on October 15, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not 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. The file shows that the provider billed codes 97016 (vasopneumatic device therapy), 97032 (electrical stimulation), 97150 (group therapeutic procedures), 97112 (neuromuscular reeducation), and 99072 (additional supplies, materials, and clinical staff time). Therefore, we decided that the Plan does not have to pay for the services rendered 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 October 20, 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 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from August 14, 2020, to August 25, 2020.

You asked the Plan to pay for the self-administered drugs. You say that you believe the self-administered drugs should be covered. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit under the Plan. The Plan also says that Part B generally does not pay for self-administered drugs, and the enrollee may have been enrolled into a Part D plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from August 14, 2020, to August 25, 2020.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 you are not strong enough to go home and you have no one to care for you at home. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of atrial fibrillation, hypertension, foot and ankle swelling and is living at home with complaints of increasing weakness. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for ambulance services provided on December 11, 2020.

You asked the Plan to waive the coinsurance for the ambulance services. You say that you were transported home from the hospital, and it was non-emergency. You state you should not have to pay for the services. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC 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).

Review of the file show that you received ambulance services on December 11, 2020. You have been asked to pay 10% coinsurance of the allowed amount for ambulance services. The allowed amount is $520.01. The total
you owe is $52 ($520.01 x 10% = $52). Your 2020 EOC says that for non-emergency Medicare-covered ambulance trip, you have 30% coinsurance. Although you state this was a non-emergency ambulance trip, the 10% coinsurance was applied. The plan will not reprocess the claim with a 30% coinsurance. 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 coinsurance for ambulance services provided on December 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia for the enrollee.

You asked the Plan to pre-approve Orencia. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the member has not tried and failed the preferred step therapy drugs.

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 Orencia. Our reviewer says that Orencia is not medically reasonable and necessary for the enrollee. The patient has not tried and failed Remicade, Inflectra, or Simponi Aria. 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. Our physician reviewer found the enrollee's condition does not meet step therapy criteria for Orencia. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on February 24, 2021.

You asked the Plan to pay for the dental services. You say that when you went to pay your bill, you were advised they did not have any information from your plan. You say that you were charged the full amount. You also say that you were advised to work it out with your insurance. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also 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 and the services are listed as covered, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on May 10, 2019.

You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says the claim was received untimely.

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 ophthalmological services was not filed until December 24, 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 ophthalmological services provided on
May 10, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve PET imaging with concurrently acquired CT, skull base to mid-thigh for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested scan is not supported by the evidence-based guidelines.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested imaging is medically reasonable and necessary. Our physician reviewer found this imaging can be approved as subsequent treatment strategy for metastatic breast cancer on aromatase inhibiter.

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 services have been met. Therefore, we decided that the Plan has to pre-approve PET imaging with concurrently acquired CT, skull base to mid-thigh for the enrollee.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an outpatient surgery provided by a participating provider on October 5, 2020, to January 25, 2021.

You asked the Plan to waive the co-payment for an outpatient surgery. You say that you do not agree with such a large co-payment. The Plan denied your request. The Plan says the correct co-payment has been applied.

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 $350 co-payment for outpatient surgery/outpatient hospital facility.

You have been asked to pay a $350 co-payment for an outpatient surgery. The total amount you are being asked to pay is $1,050 ($350 x 3 surgeries = $1,050). The services that were provided are considered an outpatient
surgery; therefore, the correct co-payments have been applied. An outpatient surgery falls within the outpatient surgery/outpatient hospital facility 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 co-payment for an outpatient surgery provided by a participating provider on October 5, 2020, to January 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance services (A0429) provided on December 19, December 22, and December 25, 2020.

You asked the Plan to waive the copayments for the ambulance services. You say that the services at issue were necessary for your care. The Plan denied your request. The Plan says you were charged this cost sharing 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 $265 copayment for each ambulance trip. You had 3 ambulance trips. The Plan charged you $265 for each one of these services. 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 copayments for the ambulance services (A0429) provided on December 19, December 22, and December 25, 2020.