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

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the evidence for this procedure is lacking.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the procedure is experimental. More research is needed to show safety and efficacy of the procedure.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on November 4, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physical therapy services. 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 physical therapy services provided on
November 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient surgery services provided on October 6, 2020.

You asked the Plan to waive the copay for the services provided. You say that a surgery was not performed on you. The Plan denied your request. The Plan says the cost share is a contractual obligation.

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 $275 copay for outpatient surgery.

The file shows that you received debridement services. These services are considered surgical services. You have been asked to pay a $275 copay for the services provided. The services fall within the outpatient surgery 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 copay for the outpatient surgery services provided on October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve progressive lenses (V2781).

You asked the Plan to pre-approve progressive lenses. You say that progressive lenses were written into the prescription and should be covered. The Plan denied your request. The Plan says progressive lenses 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 does not cover progressive lenses.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan does not have to pre-approve progressive lenses (V2781).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on November 24, 2020.

You asked the Plan to pay for the dental services. You say that if your 6-month check ups are not paid, this will be your last year with this insurance. The Plan denied your request. The Plan says the dental services you received are routine in nature. The Plan also says that routine dental services are not covered.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on November 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the breast ultrasounds provided on November 12, 2020.

You asked the Plan to waive the copay for the ultrasound services. You say that your annual mammogram is not enough to screen for breast cancer. The Plan denied your request. The Plan says the cost share 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 $160 copay for each Medicare-covered radiological diagnostic services. 

The file shows you received a left breast ultrasound and a right breast ultrasound. A $132.17 copay was applied to each ultrasound. Because the amounts were less than the $160 copay, you were charged the lesser amount. The services fall within the outpatient diagnostic tests 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 copay for the breast ultrasounds provided on November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673).

You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on February 5, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the services provided to the enrollee by an out-of-network provider on February 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 10, 2020.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services on November 10, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 10, 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 November 12, 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 12, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for psychotherapy provided on October 26, 2020 and November 2, 2020.

You asked the Plan to waive the co-payment for the psychotherapy. You say that you were told any telehealth appointments were free during the pandemic. You say that your co-payments are not correct. The Plan denied your request. The Plan says the co-payments 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 a $40 co-payment for each in-network, Medicare-covered individual therapy session.

You have been asked to pay a $40 co-payment for each visit for psychotherapy. The total amount you owe is $80 ($40/visit x 2 visits = $80). The psychotherapy falls within the "Outpatient Mental Health Care" benefit category. The Plan says that co-payments for outpatient mental health services are not being waived. 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 psychotherapy provided on October 26, 2020 and November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, and palliative (emergency) treatment of dental pain provided on January 11, 2021.

You asked the Plan to pay for the intraoral periapical x-rays and emergency treatment. You say that you were not advised that your enhanced package would not roll over into the 2021 plan year. You also say that you believe these services should be covered. The Plan denied your request. The Plan says these procedures are not covered benefits under your dental plan. The Plan also says that you were not effective on the enhanced dental plan until February 1, 2021.33.

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. At the time these services were rendered you were only covered for the included non-Medicare preventive dental services. Your enhanced dental benefit did not go into effect until February 1, 2021 which is why these services are not covered. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, and palliative (emergency) treatment of dental pain provided on January 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI scan of the joint of the lower extremity (73721) to be provided by an OON provider.

You asked the Plan to pre-approve an MRI of the knee. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for OON care have not been met.

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 provider at issue in this case is not a network provider with the Plan. 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 an MRI of the knee. Our reviewer says that the requested service is not emergent or urgent care. Our physician reviewer found that the enrollee has osteoarthritis of the knee. The provided records do not support the necessity of emergent or urgent out of network services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the knee have not been met.

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 an MRI of the knee. Therefore, we decided that the Plan does not have to pre-approve an MRI scan of the joint of the lower extremity (73721) to be provided by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 11 additional home health skilled nursing assessments.

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 services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has been receiving home health services since at least February of 2021. He has been receiving skilled nursing services for disease teaching for pneumonia, diabetes and skin care. The documentation indicates he has reached his goals as his spouse is independent with medications and administers the medication to the patient as prescribed and is knowledgeable regarding his medical conditions. His wife is his caregiver and she has been instructed on assisting the member with his home exercise program and mobility training. There is no indication that the member has a feeding tube, parental medications or complex wound care issues. There is no indication that the member had any recent medication changes or hospitalizations. There has not been a recent decline in function and the member has been medically stable. The documentation doesn't support that the enrollee requires additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary.

The enrollee does not require additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The requested home health services are 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 11 additional home health skilled nursing assessments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an office visit provided on October 13, 2020.

You asked the Plan to waive the co-payments for office visit. You say that this visit was to receive instructions to undergo a colonoscopy screening. The Plan denied your request. The Plan says the co-payments amount 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $40 co-payment for in-network specialist visit.

You have been asked to pay $40 co-payment for office visit. Office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 office visit provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam Therapy.

You asked the Plan to pre-approve Radiation treatment delivery, >/=1 MeV; complex (77412). You say that Proton Beam Therapy represents a very reasonable strategy. The Plan denied your request. The Plan says proton beam is not considered medically necessary for this type of cancer.

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 Radiation treatment delivery, >/=1 MeV; complex (77412). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the theoretical advantage of proton beam therapy is in its dose distribution. Proton beam therapy thus permits the delivery of high doses of RT to the target volume while limiting the "scatter" dose received by surrounding tissues. Use of proton beam RT is expanding as more proton beam treatment centers open. There is no data to support the superiority of proton therapy over standard radiation therapy. In addition, the patient has not yet been evaluated by a radiation oncologist. The service 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 Radiation treatment delivery, >/=1 MeV; complex (77412) have not been met. Therefore, we decided that the Plan does not have to pre-approve Proton Beam Therapy.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for emergency room services provided by a participating provider on December 17, 2020.

You asked the Plan to waive the co-payment for emergency room services. You say that you do not feel like you should be responsible for this. 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 $50 co-payment for emergency care.

You have been asked to pay a $50 co-payment for emergency room services. Since emergency room services were provided, the correct co-payment has been applied. Emergency room services fall within the emergency care 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 emergency room services provided by a participating provider on December 17, 2020.