Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 27, 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. The HCPCS/CPT Code Manual definition of code J1955 is injection, levocarnitine, per 1 gm.

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, J1955, 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 August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), the limited oral evaluation (D0140), and the periapical x-ray (D0220) provided on January 6, 2020.

You asked the Plan to pay for the dental services. You say that the provider guaranteed that this claim was sent out immediately and did not miss any deadlines. You also say that a little leniency might be used during this year of pandemic whereas some people do have limited staff and shorter hours. The Plan denied your request. The Plan says the claim for services was received outside the allowed time frame of 12 months from the service date.

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 dental services was not filed until January 19, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), the limited oral evaluation (D0140), and the periapical x-ray (D0220) provided on January 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on September 29, 2020.

You asked the Plan to pay for the psychotherapy. You say that the service was provided with no adequate time to obtain authorization. You say that the records reflect the medical necessity for the service and the claim should be reprocessed for payment. The Plan denied your request. The Plan says authorization for out of network services was not obtained.

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 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 psychotherapy provided by an out-of-network provider on September 29, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on December 24, 2020 by an OON provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.

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 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 domiciliary or rest home visit provided on December 24, 2020 by an OON provider.
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 3, 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. The HCPCS/CPT Code Manual definition of code J1955 is injection, levocarnitine, per 1 gm.

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, J1955, 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 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our physician reviewer found that the enrollee was admitted to the acute care hospital with Covid-19, respiratory failure, and encephalopathy. LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2200) and spectacle fitting (92341)
provided on October 27, 2020.

You asked the Plan to pay for the glasses and fitting. You say that these services were necessary and provided
by staff at the nursing facility where the enrollee resides. The Plan denied your request. The Plan says glasses
must be provided by the Plan's specified vision vendor in order to be eligible for coverage. In addition,
spectacle fittings are not covered by Medicare or by the Plan's supplemental vision benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers one routine eye exam per year when provided by a network provider or the Plan's
specified routine vision vendor. The Plan will also provide a $100 credit toward the purchase of eyeglasses or
contact lenses every two years when purchased from the specified vision vendor.

We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's routine vision
network. Eyeglasses must be provided by the specified vendor. In addition, a spectacle fitting is not covered by
Medicare, nor is it listed as a covered service under the supplemental routine vision benefit. Based on this
information, we decided that the Plan's rules for coverage of the glasses and fitting have not been met.
Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2200) and spectacle
fitting (92341) provided on October 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on January 12, 2021.

You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you were not advised you would have a coinsurance responsibility. You say that the coinsurance should be covered. The Plan denied your request. The Plan says the coinsurance applied correctly.

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 20% coinsurance for Medicare-covered therapeutic radiology services, including, but not limited to radiation therapy and/or hyperbaric oxygen.

You have been asked to pay $112.55, which is 20% of the allowed amount for the radiation therapy services. The allowed amount is $562.71 (20% x $562.71 = $112.55). Radiation therapy services 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 coinsurance for radiation therapy services provided on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Ferritin (8278), Cyanocobalamin (Vitamin B-12)(82607),
Folic acid (82746), Hemoglobin (83036), Antibody; HIV-1 and HIV-2 (86703), Iron (83540) and Transferrin
(84466) provided on December 7, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says these services are non-covered because
screening testing is not covered by Medicare.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare
does not cover this test solely for screening purposes. Additionally, the documentation submitted does not
include any medical records to verify why this testing was ordered and if Medicare coverage criteria have been
met. Therefore, we decided that the Plan does not have to pay for Ferritin (8278), Cyanocobalamin (Vitamin B-
12)(82607), Folic acid (82746), Hemoglobin (83036), Antibody; HIV-1 and HIV-2 (86703), Iron (83540) and
Transferrin (84466) provided on December 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the vertebral augmentation provided on October 30, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the vertebral augmentation. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 vertebral augmentation provided on October 30, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on September 19, 2019.

You asked the Plan to pay for the services provided. You say that the ordering physician attests that the testing was medically necessary for the enrollee. The Plan denied your request. The Plan says the testing was not ordered by the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file, and Medicare rules. The records provided did not show that the testing was ordered for a specific medical problem and that the results would be used in the management of the enrollee's specific medical problem. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on September 19, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Neulasta.

You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says that the enrollee's lack of significant comorbidities does not place the enrollee at moderate to high risk for febrile neutropenia.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Neulasta. Our physician reviewer found that the requested use of Neulasta is FDA-approved for the enrollee's diagnosis. The enrollee's risk of neutropenia is increased by his age and alcohol use, coupled with a chemotherapy regimen of intermediate risk of neutropenia. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have been met. Therefore, we decided that the Plan has to pre-approve Neulasta.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray, or pay more for the prophylaxis, bitewing x-rays, periodic oral evaluation, and first intraoral periapical x-ray provided on January 7, 2021 by an OON provider.

You asked the Plan to pay for the additional intraoral periapical x-ray, and to pay more for the prophylaxis, bitewing x-rays, periodic oral evaluation, and first intraoral periapical x-ray. You say that this was your first dental claim. The Plan denied your request. The Plan says benefits for additional intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded. The Plan also says that these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.

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, intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray on January 7, 2021 which was covered by the Plan and your intraoral x-rays benefit has been exhausted. You are also responsible for the coinsurance plus the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray, or pay more for the prophylaxis, bitewing x-rays, periodic oral evaluation, and first intraoral periapical x-ray provided on January 7, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payments for the office visit (99214), the Moh's surgery (17311), and the tangential biopsy of skin (11102) provided on October 27, 2020 and November 25, 2020.

You asked the Plan to waive the co-payments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payments have been applied correctly to the services provided.

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 $50 co-payment for each specialist visit for Medicare-covered benefits. Additionally, you pay a $350 co-payment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.

You have been asked to pay $615.04 which includes a co-payment of $215.04 for the tangential biopsy of skin; this is the Plan allowed amount which is less than the applicable co-payment for this service. This amount also includes a $350 co-payment for the Moh's surgery and a $50 co-payment for the specialist office visit provided. 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-payments for the office visit (99214), the Moh's surgery (17311), and the tangential biopsy of skin (11102) provided on October 27, 2020 and November 25, 2020.