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

We decided that the Plan has to pre-approve a tertiary level of care with an out-of-network provider.
You asked the Plan to pre-approve the out-of-network tertiary care. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says that the records did not support the need for the member to go to tertiary care level nephrology.
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 out-of-network tertiary care. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there is very high morbidity and mortality associated with the diagnosis of this member and it is reasonable, given the likely outcomes of this member, to seek second opinion and tertiary care opinion on management. 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 out-of-network tertiary care have been met. Therefore, we decided that the Plan has to pre-approve a tertiary level of care with an out-of-network provider.
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: 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 22, 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 22, 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 August 10, 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 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for eyewear provided on October 14, 2020.
You asked the Plan to reimburse you for the eyewear. The Plan denied your request. The Plan says members are responsible for any amount over $150 for coverage of supplemental eyewear.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan has reimbursed you $150 for the eyewear. Therefore, we decided that the Plan does not have to reimburse you an additional amount for eyewear provided on October 14, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the eyelid surgeries provided on November 17, 2020 described by codes 15823 and 67900.
You asked the Plan to pay for the eyelid surgeries. You say that you feel that this should be covered because you were not aware that the primary payer had changed, and your Plan does not require prior authorization since it is a Preferred Provider Organization (PPO). The Plan denied your request. The Plan says that these services were authorized by your secondary insurance. No authorization was requested of this Plan. As such, no payment is required by the Plan.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were provided with the eyelid surgeries by a contract provider. The contract does not clearly indicate which services would require prior authorization. The website referred to in the EOC simply directs the enrollee back to the exact same page of the EOC when selecting Prior Authorization List. As such, you were not reasonably aware that this would have required prior authorization, and it would be the responsibility of the network provider to obtain said authorization. Under Medicare rules, this means the eyelid surgeries are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the eyelid surgeries provided on November 17, 2020 described by codes 15823 and 67900.
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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3020).
You asked the Plan to pre-approve foot orthotics. You say that the orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services (99285) provided on August 11, 2020.

You asked the Plan to pay for the emergency room services. You say that you would like reconsideration because this service was billed appropriately. The Plan denied your request. The Plan says the documentation does not support CPT code 99285.

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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

We asked our coder 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 room services. Our reviewer says that CPT code 99285 does not meet criteria for billing or reimbursement consideration. Our reviewer found the emergency room visit does not support the 3 criteria (Comprehensive History, Comprehensive Exam and Medical Decision Making of High Complexity). The documentation supports CPT 99282 ("95" guidelines) Expanded Problem Focused History, Detailed Exam, and Medical Decision Making of low complexity. Therefore, CPT 99285 would be inappropriate code to report for this service.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services (99285) provided on August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Mic-Key GI tube kits (B9998) provided on January 5, 2021.
You asked the Plan to pay for the Mic-Key GI tube kits. You say that you would like reconsideration because this equipment is unrelated to the member's Total Parenteral Nutrition Therapy. The Plan denied your request. The Plan says CMS recommends a specific code for the billed item.
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 asked our coder 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 Mic-Key GI tube kits. Our reviewer says that CPT code B9998 does not meet criteria for billing or reimbursement consideration. Our reviewer found per CMS "Correct coding requires the use of a specific HCPCS code for an item when a specific code exists. Use of a Not
Otherwise Classified code in place of a specific code represents incorrect coding". A more appropriate code exists for this service. 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 Mic-Key GI tube kits have not been met. Therefore, we decided that the Plan does not have to pay for the Mic-Key GI tube kits (B9998) provided on January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Omnipod which is represented by Current Procedural Terminology (CPT) code A9274.
You asked the Plan to pre-approve the Omnipod. You say that the enrollee has type 1 diabetes and has been using Omnipod for several years. The Plan denied your request. The Plan says the requested disposable insulin delivery does not meet the definition of durable medical equipment and is thus not covered under the Medicare medical benefit.
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including elastomeric infusion pumps, are non-covered devices because they do not meet the Medicare definition of durable medical equipment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Omnipod have not been met. Therefore, we decided that the Plan does not have to pre-approve an Omnipod which is represented by Current Procedural Terminology (CPT) code A9274.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 9, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam therapy for the enrollee.
You asked the Plan to pre-approve Proton Beam therapy. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for Proton Beam Therapy (PBT). The Maximus Physician Reviewer determined this treatment was necessary. The Plan argues that proton beam therapy is considered reasonable in instances where sparing the surrounding normal tissue cannot be adequately achieved with photon -based radiotherapy and is of added clinical benefit to the patient. The Plan notes that the provider states that the enrollee is a good candidate for either intensity-modulated radiation therapy or proton beam therapy. The medical records show the enrollee is a 69-year-old man with a diagnosis of stage IIIA prostate cancer. The Radiation Oncology Follow-up Consultation Note dated January 13, 2021 documents that the enrollee would be a candidate for brachytherapy alone, and that he is a good candidate for either intensity-modulated radiation therapy or proton beam therapy. Our Medical Director has concluded that the Plan is correct in this case. The Medicare LCD L35075 states that proton beam therapy is considered reasonable in instances where sparing the surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy and is of added clinical benefit to the patient. It has not been adequately demonstrated in this case that sparing the surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy and is of added clinical benefit to this enrollee. Medicare criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Proton Beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Proton Beam therapy for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied for the home health aide services
(S9122) provided January 1, 2021, through January 31, 2021.
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the deductible must be met before the
coinsurance is applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $1,000 deductible each calendar year.
This is the amount the enrollee has to pay out-of-pocket before the Plan will pay their share of covered medical
services. Until the enrollee has paid the deductible amount, the enrollee must pay the full cost for most of their
covered services. Additionally, the enrollee must pay a 20% coinsurance for out-of-network home health care.
The enrollee has been asked to pay a $618.45 deductible for the home health aide services provided. This is the
Plan allowed amount for the services provided. The enrollee must pay a $1,000 deductible each calendar year
before the Plan will pay their share of covered medical services. This means that the enrollee has been asked to
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive
the deductible applied for the home health aide services (S9122) provided from January 1, 2021, through
January 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea fluid flow joint injection (Q4206).You asked the Plan to pre-approvea fluid flow joint injection. You say that the requested treatment is a medical necessity for the enrollee.The Plan denied your request. The Plan says the requested procedure is not medically supported.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 a fluid flow joint injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has chronic low back pain. The enrollee is taking Hydrocodone and Pregabalin. There is no evidence supporting the use of Amniotic Fluid injection for chronic low back pain.This solution is not cleared by the FDA for this use.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a fluid flow joint injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea fluid flow joint injection (Q4206).