Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power scooter provided on May 26, 2020.

You asked the Plan to pay for power scooter. You say that this scooter has dramatically changed your life for the better. The Plan denied your request. The Plan says the denial of payment for this item is correct, because the documentation does not show that a cane, walker, or manual wheelchair would not be able to meet your mobility needs, and your home was not evaluated to be sure it can accommodate a scooter.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 power scooter. Our reviewer says that this power scooter does not meet the Medicare criteria for coverage. Our physician reviewer found the documentation indicates that you have a mobility deficit, but it is not clear that this deficit impairs mobility-related activities of daily living (MRADLs) in the home. The documentation reveals that you can use a cane. The documentation does not support that you can safely maneuver the requested scooter within your home. This power scooter was not 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 power scooter have not been met. Therefore, we decided that the Plan does not have to pay for a power scooter provided on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 2, 2021 by an out of
network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan
denied your request. The Plan says no prior authorization was 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 office visit provided on March 2, 2021 by an
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitored anesthesia care provided on December 11, 2020.

You asked the Plan to pay for the anesthesia care. The Plan denied your request. The Plan says the diagnosis codes do not support these services.

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 pay for the anesthesia care. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was determined to be an ASA class 1 anesthetic risk. The provided medical records do not support that monitored anesthesia services were medically reasonable and necessary as defined by Medicare rules. The elements of the coverage criteria 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 the anesthesia care have not been met. Therefore, we decided that the Plan does not have to pay for the monitored anesthesia care provided on December 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 23, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a cardiac pacemaker.
You asked the Plan to pre-approve pacemaker. You say that the enrollee has evidence of tachycardiabradycardia
syndrome and atrial fibrillation with very rapid ventricular rates. The Plan denied your request.
The Plan says the enrollee does not meet the coverage criteria for the requested cardiac pacemaker, and this is
not medically necessary.
The Plan follows Medicare rules. Medicare rules state that implanted cardiac pacemakers may be covered or
excluded from coverage based on certain clinical indications.
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 pacemaker. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested cardiac pacemaker. Our physician reviewer found
the enrollee has atrial fibrillation with rapid ventricular response and occasional asymptomatic bradycardia.
The record does not show that the enrollee has an indication for coverage. The record shows that the enrollee
has atrial fibrillation without symptomatic bradycardia which is an exclusion from coverage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of pacemaker have not been met. Therefore, we decided that the Plan does not
have to pre-approve insertion of a cardiac pacemaker.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 11, 2021 with pathologic fracture and hypercalcemia. He underwent a right hip hemiarthroplasty on May 25, 2021. The therapy notes dated June 2, 2021 state there are no new concerns and he is weight-bearing as tolerated on the right leg.
He does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and 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 November 4, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a
Sanexas device reported on November 2, 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 CPT codes 97032, 97150, 97016, 96372, J3490, J3411, and J3415 are not supported in the
medical record. Specifically, the medical record submitted for this date of service consists of a follow up
progress note. Although injections and treatment is mentioned as part of the plan, the record does not contain a
description of the services billed. It cannot be verified that these services were performed at this visit. Based on
this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and
treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay
for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee is stable and would benefit from IRF. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's condition; the enrollee does not meet the requirements.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that based on the documentation provided, it is my opinion that the health Plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation services rendered on November 22,
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 99358 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 99358 is prolonged evaluation and management service
before and/or after direct patient care; first hour.

We find that CPT code 99358 is not supported in the medical record. Specifically, there is no documentation of
direct, face-to-face patient care for one hour. 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
prolonged evaluation services rendered on November 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92012) and office visit (99203) provided on November 6, 2020 to December 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the exam and office visit. You say that you called to get verification of coverage for this provider and were told they are covered after you did not get a straight answer. The Plan denied your request. The Plan says this provider is not in-network, and services received out-of-network are only covered in limited circumstances. The Plan also states that they could not find a record of a call where you were incorrectly advised this provider was 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 items/services at issue in this appeal. 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 eye exam (92012) and office visit (99203) provided on November 6, 2020 to December 1, 2020 by an out of network (OON) provider.
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 11, 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 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper complete denture.

You asked the Plan to pre-approve these services. You say that the enrollee needs a new denture due to full extraction of upper teeth. The Plan denied your request. The Plan says the enrollee has exhausted the benefit limit.

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. The Plan covers one upper and one lower complete denture every five years. 

We looked at the file and the Plan's rules. The file shows that the enrollee received a complete denture on October 4, 2019 that the Plan covered. The enrollee is not eligible for a new complete denture until five years have passed from that date. Therefore, we decided that the Plan does not have to pre-approve an upper complete denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehab therapy for strengthening, and close physician management. The Plan denied your request. The Plan says it is not reasonable to expect the enrollee to participate in daily intensive therapies.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our physician reviewer found that the enrollee was admitted to the acute care hospital with pneumonia, sepsis, and respiratory failure. He is at a standby assist level for standing up, contact guard assist for walking, and contact guard assist for toilet transfers. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.