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

We decided that the Plan does not have to pay for the preventive procedure provided on February 1, 2021.

You asked the Plan to pay for the preventive procedure. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.

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 preventive procedure provided on February 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on August 19, 2020.

You asked the Plan to pay for the therapeutic procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that this service was performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate code to be billed for this service. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on August 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on December 31, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on December 31, 2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on August 12, 2020.You asked the Plan to waive the copayment for an MRI. You say that you receive assistance for copayments but are being billed the full amount by the provider.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 $275 copayment for advanced imaging services provided at an outpatient hospital facility. 
You have been asked to pay a $275 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on August 13, 2020.You asked the Plan to pay for the core buildup. You say that you would like this service to be covered.The Plan denied your request. The Plan says this service is 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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided on August 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for enteral feeding supplies (B4035, B4150, B9002) provided from December 1, 2020, to December 31, 2020

You asked the Plan to pay for enteral feeding supplies. You say that these items were provided during a non-covered stay. The Plan denied your request. The Plan says these items were billed with POS 31, indicating a covered SNF stay.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.

The POS billed on the claim shows that enteral feeding supplies were used in a SNF. Therefore, we decided that the Plan does not have to pay for enteral feeding supplies (B4035, B4150, B9002) provided from December 1, 2020, to December 31, 2020
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a intrathecal pump trial.
You asked the Plan to pre-approve a intrathecal pump trial. You say that you would like reconsideration
because the requested pump is medically necessary. The Plan denied your request. The Plan says the record
does not provide evidence that other methods to manage the member's spasticity were trialed and failed.
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 intrathecal pump trial. 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 documentation submitted as to the failure of oral agents to treat her
spasticity. Without this fundamental documentation, the request cannot meet NCD criteria.
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 intrathecal pump trial have not been met. Therefore, we decided that the Plan
does not have to pre-approve a intrathecal pump trial.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on August 18, 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 procedure code 97163 is not supported.

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 97163 is physical therapy evaluation, high complexity, typical time with patient 45 minutes.

We find that CPT code 97163 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 pay for the physical therapy services rendered on August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the first intraoral periapical x-ray and or pay for the pin retention provided on February 1, 2021 by an OON provider.

You asked the Plan to pay more for the first intraoral periapical x-ray and to pay for the pin retention. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that this provider charges more than the Plan allowed amount for these services provided.

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, you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the first intraoral periapical x-ray and or pay for the pin retention provided on February 1, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on January 14, 2021.You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you would like these services to 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 items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services/supplies (A4223) provided December 9, 2020 to January 14, 2021.

You asked the Plan to pay for the infusion supplies. You say that after your back surgery you had a PICC line inserted and was told you needed antibiotics to be done 3 times a day for 6 weeks to prevent you from being paralyzed or death, which at this point you felt you didn't have a choice. The Plan denied your request. The Plan says this service is not a covered benefit.

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 A4223 GY is infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately). 

We find that CPT code A4223 GY is not supported in the medical record. Specifically, the claim was billed with a GY modifier. The GY modifier is an immediate indication that the service would not be covered or is not a covered benefit under the plan. Claims that are billed with the GY modifier are denied for payment. Based on this information, we decided that Medicare rules for coverage of the infusion supplies have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services/supplies (A4223) provided December 9, 2020 to January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve plasma rich protein for ankle pain.

You asked the Plan to pre-approve plasma rich protein for ankle pain. You say that this request is medically necessary. The Plan denied your request. The Plan says research has not shown that this is good as or better than other treatment or procedure.

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 plasma rich protein for ankle pain. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this 72-year-old woman sustained a traumatic injury to her left ankle However, the requested procedure is, at this time, considered experimental/investigational. Therefore, this request is deemed 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 plasma rich protein for ankle pain have not been met. Therefore, we decided that the Plan does not have to pre-approve plasma rich protein for ankle pain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift chair and mechanism provided on May 27, 2020.

You asked the Plan to pay for a seat lift chair and mechanism. You say that you were told by the provider that no prior authorization was required for the requested item. The Plan denied your request. The Plan says Medicare criteria for a seat lift mechanism have not been met.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. 

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 a seat lift chair and mechanism. Our reviewer says that the requested item is not medically necessary. Our physician reviewer found that the record indicates you are mainly in bed and unable to do most activities. The records provided do not indicate that the requested service is part of the treating physician's course of treatment or that you have complete inability to stand from a regular chair. The elements of the coverage rule are not satisfied. 

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 seat lift chair and mechanism have not been met. Therefore, we decided that the Plan does not have to pay for a seat lift chair and mechanism provided on May 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by current procedural terminology (CPT) code 97110 provided on July 28, 2020.You asked the Plan to pay for CPT code 97110. 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 covered 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 CPT Code Manual definition ofcode 97110 is Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.We find that CPT code 97110 is not supported in the medical record. Specifically, the medical records indicate that the services were performed by a physical therapist assistant in the home health or hospice setting. There is a more appropriate CPT code that should be used to bill for therapy services provided in the home health setting. Based on this information, we decided that Medicare rules for coverage of CPT code 97110 have not been met.Therefore, we decided that the Plan does not have to pay for the therapy services represented by current procedural terminology (CPT) code 97110 provided on July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shipping costs for services on July 31, 2020 to September 5, 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 services are not covered.The Plan must follow Medicare rules. The rules say that items that do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member are not covered.We looked at the file and Medicare rules. The services at issue are shipping costs. These services are not used for the treatment of an illness or injury or functioning of a malformed body member. 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 pay for the shipping costs for services on July 31, 2020 to September 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses (V2781), and the deluxe frames (V2025) received January 23, 2021 from the out-of-network provider.

You asked the Plan to pay for the progressive lenses and deluxe frames. You say that you saved the Plan money by utilizing the out-of-network vendor. The Plan denied your request. The Plan says you do not have out-of-network benefits for your vision care coverage.

Medicare generally does not cover routine vision and eye-wear services. However, the Plan offers a routine vision and eye-wear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased from a Plan network vision care vendor.

We looked at the file and the Plan's rules. You do not have out-of-network benefits for your vision care coverage. If you purchase lenses and frames out-of-network, you will be responsible for the full amount. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses and deluxe frames have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lenses (V2781), and the deluxe frames (V2025) received January 23, 2021 from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three resin-based composites provided on February 8,
2021.

You asked the Plan to pay for the resin-based composites. You say that you would like these services to be
covered. The Plan denied your request. The Plan says benefits for these services have been satisfied and the
frequency limitation has been exceeded.

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, restorations are limited to two
procedures per calendar year. The record shows that you received two resin-based composites on February 9,
2021 and your restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to
pay for the three resin-based composites provided on February 8, 2021.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required provided on February 16, 2021.

You asked the Plan to pay for the core buildup. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required provided on February 16, 2021.