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

We decided that the Plan does not have to waive the coinsurance for infusion therapy services (96365, J2323, J7050) on November 4, 2020.
You asked the Plan to waive the coinsurance for infusion therapy services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 17% coinsurance for Medicare Part B prescription drugs that are rendered in an in-network outpatient hospital. The allowed amount of the claim is $4,450.39, resulting in a coinsurance obligation of $715.27. Infusion therapy services fall within the Medicare Part B prescription drugs benefit category. You are not being charged more than 17% coinsurance for the services at issue. 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 infusion therapy services (96365, J2323, J7050) on November 4, 2020.
Your complaint about the Plan processing past, similar claims differently is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildups (D2950).
You asked the Plan to pre-approve core buildups. You say that you disagree with the denial and would like the Plan to cover the service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 core buildups (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea life alert system.You asked the Plan to pre-approvelife alert system. You say that the enrollee frequently falls due to her conditions.The Plan denied your request. The Plan says this device is not primarily medical in nature and is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea life alert system.
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 4, 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 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic mammography (77066)
complete breast ultrasound (76641) diagnostic digital breast tomosynthesis (G0279) providing February 23,
2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that you are not happy with the
bill amount of $26.77 and is not happy with any responsibility amount. The Plan denied your request. The Plan
says the claim was processed and 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 diagnostic procedures and tests in an outpatient hospital.
You have been asked to pay 26.77 ($47.25 - $20.48) for the diagnostic services. The coinsurance amount amount was $47.25. Since you have already paid $20.48 then you are responsible for the remaining balance of $26.77. The diagnostic service falls within the Outpatient hospital 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 copayment for diagnostic mammography (77066) complete breast ultrasound (76641) diagnostic digital breast tomosynthesis (G0279) providing February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral evaluation (D0150) and deep cleaning (D4341) to be provided by a periodontist.
You asked the Plan to pre-approve the dental services. You say that you went to the dentist for a cleaning. You say that you were unable to have the cleaning done due to bone loss. You also say that you need to have a deep cleaning done with a periodontist. The Plan denied your request. The Plan says dental services performed by a periodontist 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 among those covered under this benefit when provided by a periodontist. Therefore, we decided that the Plan does not have to pre-approve an oral evaluation (D0150) and deep cleaning (D4341) to be provided by a periodontist.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that SNF care is medically necessary.The Plan denied your request. The Plan says the records do not show that you require daily skilled therapy or skilled nursing services that can only be provided on an inpatient basis in a SNF. The services required, including further physical therapy interventions if desired, can safely be received at a different setting.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. The enrollee had stable vital signs. He used oxygen via nasal cannula. The enrollee received physical therapy in the acute hospital. The enrollee was at a modified independent level with bed mobility, supervision/stand by assist level with transfers and contact guard assist level with gait to 250 feet. There are no identifiable skilled nursing service needs. While there are identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl patches.
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 self-administered drugs are not covered.
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 pre-approve Fentanyl patches.
Benefits for these services 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.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 the step therapy requirement is not met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Gel-One is not reasonable or medically necessary.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 Gel-One
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional acupuncture treatments for conditions other than chronic low back pain.
You asked the Plan to provide coverage for additional acupuncture treatments for conditions other than chronic low back pain. The Plan denied your request. The Plan says that the medical documentation submitted by your doctor does not demonstrate you are being treated with acupuncture for chronic low back pain. There is no exception that would allow us to cover more than the 12 acupuncture visits for conditions other than chronic low back pain under your supplemental
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file, the Medicare rules and the Plan's rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the file shows that the claim records show that you have used 11 of your acupuncture visits under your supplemental benefit for conditions other than chronic low back pain. Therefore, we decided that the Plan does not have to provide coverage for additional acupuncture treatments for conditions other than chronic low back pain.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76937, 36410) provided November 4, 2020.

You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 76937, & 36410 is not supported in the medical record. Specifically, the claim was billed with Place of Service 22 (Outpatient). The records show the enrollee was an inpatient at the time the service was provided. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76937, 36410) provided November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the care and services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the care and services. You say that the enrollee would like to be evaluated by an outside provider and you believe a second opinion is within reason. The Plan denied your request. The Plan says the provider is out-of-network.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the care and services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.

You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says additional services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 services. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the plan. She has had prior outpatient therapy visits and the records do not demonstrate that the unique skills of a professional therapist are required to provide treatment. She has had instruction in a home exercise program. The requested services are not part of a maintenance program, and are not required to establish, design and/or deliver a program to maintain her current condition or to prevent or slow further deterioration.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a myoelectric elbow-wrist-hand-finger orthosis to be provided by an out of network provider.
You asked the Plan to pre-approve a myoelectric elbow-wrist-hand-finger orthosis (L8702). You say that the enrollee continues to remain with a severely weak right upper extremity. The Plan denied your request. The Plan says a myoelectric elbow-wrist-hand-finger orthosis is available in-network.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a myoelectric elbow-wrist-hand-finger orthosis to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay the supplemental vision benefit of $200 for eyeglasses provided on
February 9, 2021.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says that the vision
services paid with a member responsibility of $214.40.
The Plan must follow Medicare rules. 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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has not responded to multiple requests from us to explain why the Plan
only paid $120 toward the eyeglasses. Therefore, we decided that the Plan has to pay the supplemental vision
benefit of $200 for eyeglasses provided on February 9, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on May 11, 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 procedure codes 44143 and 44139 are not supported.
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 CPT Code Manual definition of code 44143 is colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure). The definition of code 44139 is mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure). We find that CPT codes 44143 and 44139 are not supported in the medical record. Specifically, there is no
documentation of a partial colectomy with end colostomy and closure of distal segment to support code 44143. Given that the primary code is not supported, add-on code 44139 is also not supported. 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 pay for the surgical services rendered on May 11, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits provided on August 29, 2019, and October 10, 2019, billed with code 99347.
You asked the Plan to pay for the home visits. You say that these services were medically necessary. The Plan denied your request. The Plan says this code cannot be billed for services when the physician is not physically present.
The Plan must follow Medicare rules. Medicare rules say that a home visit cannot be billed by a physician unless the physician was actually present in the beneficiary's home. The records show that these visits were performed by a nurse. There is no evidence that the billing physician was physically present in the enrollee's home. Therefore, we decided that the Plan does not have to pay for the home visits provided on August 29, 2019, and October 10, 2019, billed with code 99347.