Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and topical application of fluoride varnish (D1206) provided on December 1, 2020.
You asked the Plan to pay for the prophylaxis and topical application of fluoride varnish. You say that you thought the Plan would cover 3 cleanings per year. The Plan denied your request. The Plan says these services exceed the frequency limitations in your benefit plan. The Plan also verified that your last call to the Plan was in October 2020, which was not regarding your benefits, and no calls were made to the Plan directly prior to this date of service.
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, prophylaxis (D1110) and topical application of fluoride varnish (D1206) are each limited to two procedures per plan year. The record shows that you received a prophylaxis (D1110) and topical application of fluoride varnish (D1206) on January 20, 2020, and August 18, 2020, and your prophylaxis (D1110) and topical application of fluoride varnish (D1206) benefits had been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) and topical application of fluoride varnish (D1206) provided on December 1, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for to pay for the emergency department visit (99285) provided September 16, 2020.
You asked the Plan to pay for the emergency visit. You say that you are requesting review of the attached emergency department record, reprocess and approve the claim at the appropriate reimbursement rate for the E/M code billed. The Plan denied your request. The Plan says that the documentation does not support the E/M level as reported on the claim. For this date of service, the E/M code of 99284 will remain paid.
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided. In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status): 1. a comprehensive history; 2. a comprehensive examination; and 3. medical decision making of high complexity. In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function. 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 pay for the emergency visit. Our reviewer says that the medical records support the coding of 99285. Our physician reviewer found the enrollee has an extensive psychiatric history and presented with chest pain and vaginal bleeding and stated she had recently been released from another hospital for cardiac issue. The provided documentation reflects a comprehensive history and examination as well as high complexity decision making. The presenting complaint is chest pain that reasonably is deemed cardiac in origin. The documentation satisfies the elements of the coverage rule. 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 emergency visit have been met. Therefore, we decided that the Plan has to pay for to pay for the emergency department visit (99285) provided September 16, 2020.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lucentis.
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 left eye exudative
macular degeneration with active choroidal neovascularization. He has not tried and failed the Plan's required
drug, Avastin. The records do not show that the required drug would be contraindicated or less effective;
therefore, Lucentis 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 Lucentis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the Medicare criteria for reasonable and necessary are not met as it has not been shown to be safe and effective in long term studies and there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion device placement surgery at L3-4 and L5-S1 is not medically reasonable or 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS (CPT code(s): C2624 and 33289), for the enrollee.
You asked the Plan to pre-approve the CardioMEMS. You say that the enrollee has heart failure and the device is necessary. The Plan denied your request. The Plan says that the services are considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 CardioMEMS. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found given the symptoms of recurrent congestive heart failure (CHF) which appears very sensitive to volume loading conditions, the complexity of the medical regimen and managing the enrollee's diuretics to maintain euvolemia, as well as the failure to prevent acute CHF hospitalization in this enrollee, the use of the Cardiomems device is reasonable and has clinical data, expert opinion, and approved Food and Drug Administration (FDA) indications to back up its use in selected appropriate clinical situations like this one. Therefore, it would meet the medical reasonableness and necessity criteria of the applicable CMS Section 1862(a) 1(A) rule and would not be considered investigational in this clinical situation. 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 CardioMEMS have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS (CPT code(s): C2624 and 33289), 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care for EGD, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed (CPT code 43210), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the planned procedure listed under CPT Code 43210 is not listed on the CMS inpatient only list. The Plan states the procedure is currently approved as an ambulatory procedure, and there is not documentation provided to support the expectation the enrollee requires a greater than two (2_ midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee has gastroesophageal reflux disease and is scheduled to have an EsophyX procedure. The medical records submitted do not indicate a reasonable expectation of a length of stay spanning two (2) or more midnights. The enrollee may be placed into observation until it is clearly expected that a second midnight would be required, at which time the physician may order inpatient admission. The elements of the inpatient coverage rule are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care for EGD, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed (CPT code 43210), for the enrollee.
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 6, 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 August 6, 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. 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 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 reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee underwent radical nephrectomy, and partial gastrectomy and duodenectomy with a loop gastrojejunostomy. He continues to receive acute care services and these have not been denied. The records do not show that he is not currently receiving but that would be available at the LTACH facility. The LTACH 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services billed with current procedural terminology (CPT) code A0429 provided on October 14, 2020.
You asked the Plan to pay for CPT code A0429. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. The rules say in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements. We looked at the file and Medicare rules. In this case, the file shows that the enrollee's time of death pronouncement was after dispatch and before the enrollee was loaded onboard the ambulance. Medicare payment is based on the provider's/supplier's BLS base rate, no mileage or rural adjustment is reported, and the provider/supplier must use the QL modifier when submitting the claim. In this situation, the correct CPT code to bill is A0428 for non-emergency services after assessment. Therefore, we decided that the Plan does not have to pay for the ambulance services billed with current procedural terminology (CPT) code A0429 provided on October 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee does not need to remain in
the acute care hospital. The Plan denied your request. The Plan says the enrollee does not require 6.5 hours of
daily nursing care or daily physician evaluation.
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 is currently undergoing treatment at an acute care hospital (ACH) for postoperative
bowel perforation and abdominal abscesses. The enrollee is not intubated/ventilated. There is no
evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed
to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.
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 LTACH services.
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 28, 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 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code 99214) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office visit. You say that the services are necessary. The Plan denied your request. The Plan says medically necessary care is available in-network. The Plan states there are no extenuating circumstances making it medically necessary to obtain the service 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 office visit (CPT code 99214) to be provided by an out-of-network provider.