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 September 17, 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 September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extremity (arterial) study (CPT code 93923).

You asked the Plan to pre-approve the study. You say that the service is medically necessary. The Plan denied your request. The Plan says there is insufficient documentation that establishes medical necessity for the requested arterial extremity study.

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 study. Our physician reviewer found a venous extremity study was performed which visualized resolution of a deep vein thrombosis (DVT) in the left popliteal vein (January 5, 2021). An extremity arterial study (CPT 93923) was ordered and requested, ordered in August 2020 for diagnosed claudication. Recent (within sixty (60) days) notes were not provided to show signs or symptoms suggestive of claudication or any other diagnosis which might warrant an arterial study as requested. Therefore, without sufficient support made, this request for such will be considered not medically necessary 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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve extremity (arterial) study (CPT code 93923).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ambulance transport provided on
November 7, 2020.

You asked the Plan to waive the co-payment for the ambulance transport. You say that you want to know why
you had to pay the ambulance co-payment if all co-payments were waived. The Plan denied your request. The
Plan says the co-payment 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 $200
co-payment for Medicare-covered ambulance services. Cost sharing applies for each one-way trip.

You have been asked to pay a $200 co-payment for the ambulance transport. The ambulance transport falls
within the "Ambulance services" benefit category. The Plan says that only cost share for primary care and
specialty care visits were 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 the
ambulance transport provided on November 7, 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 September 29, 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 September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
October 16, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are
available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 by an out-of-network provider on October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on August 12, 2020.

You asked the Plan to pay for knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf (L1833) and addition to lower extremity orthosis, suspension sleeve (L2397). You say that the Plan should pay this claim. The Plan denied your request. The Plan says they are unable to discover any evidence of an established relationship between the enrollee and the ordering physician

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 knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf (L1833) and addition to lower extremity orthosis, suspension sleeve (L2397). Our reviewer says that the orthoses are not medically reasonable and necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity.
The item coded L2397 (sleeve) is not separately payable when the base item is not covered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf (L1833) and addition to lower extremity orthosis, suspension sleeve (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on August 12, 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 October 20, 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 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D1330, D4999, D9630) received November 24, 2020.
You asked the Plan to pay for the dental services (D1330, D4999, D9630). You say that you require thorough sedation due to a low threshold for pain. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services (D1330, D4999, D9630) received November 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex.

You asked the Plan to pre-approve Vertiflex. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has spinal stenosis. The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Therefore, the enrollee does not meet criteria for the requested 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been
met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve
a continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertiflex superion interspinous device

You asked the Plan to pre-approve vertiflex superion interspinous device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 vertiflex superion interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of spinal stenosis, lumbar region with neurogenic claudication. The vertiflex device is experimental. More research is needed to show safety and efficacy of the device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of vertiflex superion interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve vertiflex superion interspinous device
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 7, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 by an out-of-network provider on January 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy (PT) and specialist
services rendered on May 27, 2020.

You asked the Plan to waive the copayments for these services. You say that you should only have one
copayment. The Plan denied your request. The Plan says the copayments were 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 $35
copayment per Medicare-covered visit for physical therapy and a $35 copayment per visit to a specialist.

Review of the file shows that you received PT services on May 27, 2020. You have been asked to pay a $35
copayment for these services. These services fall within the physical therapy benefit category. This means that
you have been asked to pay the correct amount based on your contract with the Plan.

The file shows that you received needle insertion services from a specialist on May 27, 2020. You have been asked to pay a $35 copayment for these services. These services fall within the specialist visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.

The total amount you have been asked to pay for these services is $70. 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 copayments for the physical therapy (PT) and specialist services rendered on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem-focused oral exam, palliative treatment,
panoramic x-ray, dental extraction, and sedation, you received on January 25, 2021, and February 2, 2021.
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your
request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among
those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage.
Problem-focused oral exams, palliative treatment, panoramic x-rays, and extractions are not covered. Sedation
is also not covered when provided for other non-covered services. Therefore, we decided that the Plan does not
have to pay for the problem-focused oral exam, palliative treatment, panoramic x-ray, dental extraction, and
sedation, you received on January 25, 2021, and February 2, 2021.