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

We decided that the Plan does not have to pay for the chiropractic services coded as 99213, 97014, 97010 and 98941 provided on November 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the chiropractic services. You say that your daughter called many times to follow up about your coverage and was given false information from member services regarding coverage. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. The services billed are considered chiropractic maintenance therapy and is not covered.

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 chiropractic services coded as 99213, 97014, 97010 and 98941 provided on November 17, 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 negative pressure wound therapy (97605) provided on
December 12, 2020.
You asked the Plan to pay for the negative pressure wound therapy. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says this device was
used directly after the member's procedure.
The Plan follows Medicare rules. Medicare rules say that a complete wound therapy program as applicable
depending on the type of wound, must have been tried or considered and ruled out prior to application of
NPWT.
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 negative pressure wound therapy. Our
reviewer says that the LCD requires that in order to qualify for negative pressure wound therapy, failure of
standard wound treatment needed to have failed, inpatient or outpatient. Our physician reviewer found the
records show that the therapy was applied directly after surgery and had not had enough time to determine if
standard treatment for the wound would be effective or not.
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 negative pressure wound therapy have not been met. Therefore, we decided
that the Plan does not have to pay for negative pressure wound therapy (97605) provided on December 12,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas machine along with (or without) subcutaneous vitamin injections provided on September 29, 2020.
You asked the Plan to pay for the Sanexas machine along with (or without) subcutaneous vitamin injections. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the use of a locally injected nutria-pharmaceuticals on areas of the body suffering from chronic pain or peripheral neuropathy is not consistent with evidence-based medicine.
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 Sanexas machine along with (or without) subcutaneous vitamin injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. 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 Sanexas machine along with (or without) subcutaneous vitamin injections have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas machine along with (or without) subcutaneous vitamin injections provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D7953, D1999, D7210) received August
14, 2020, from an out-of-network provider.
You asked the Plan to pay for the dental services (D7953, D1999, D7210). You say that the plan has not paid
50% of the cost for the services received. The Plan denied your request. The Plan says the requested services
are either not covered under your benefit, or in excess of what is covered by this 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 or the requested payment is in excess of that which is covered under
this benefit. The Plan does not offer coverage for bone replacement graft for ridge preservation (D7953) or
unspecified preventive procedure, by report (D1999). The Plan offers coverage for extraction, erupted tooth
requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated
(D7210). You can get care from an out-of-network dental provider, but you may pay more. In this case you
received the tooth extraction from an out-of-network provider. The Plan has agreed to cover 50% of the
allowed cost for the extraction. You are responsible for the 50% coinsurance, plus the difference between the
Plan's allowed amount and what was charged by the out-of-network provider. Therefore, we decided that the
Plan does not have to pay for the dental services (D7953, D1999, D7210) received August 14, 2020, from an
out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on September
20, 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 99284 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 99284 is Level 4 emergency department visit for
evaluation and management of patient with problem of high severity, including detailed history and physical
examination, and medical decision-making of moderate complexity.
We find that CPT code 99284 is not supported in the medical record. Specifically, there is no documentation to
support Level 4 ER 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 emergency room
(ER) services rendered on September 20, 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 15, 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 15, 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 28, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 28, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the services provided on April 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that no additional
payment can be made.
The Plan must follow Medicare rules. Medicare rules say that Medicare secondary payment is the lowest of the
three stated amounts.
We looked at the file and Medicare rules. According to Medicare rules, secondary payment is the lowest of the
following: (1) The actual charge by the supplier (or the amount the supplier is obligated to accept as payment in
full if that is less than the charges) minus the amount paid by the primary payer; (2) The amount that Medicare
would pay if the services were not covered by a primary payer; (3) The higher of the Medicare fee schedule,
Medicare reasonable charge, or other amount which would be payable under Medicare (without regard to any
applicable Medicare deductible or coinsurance amounts) or the primary payer's allowable charge (without
regard to any deductible or co-insurance imposed by the policy or plan) minus the amount actually paid by the
primary payer. In this case, the amount correlating to condition (1) is $126, condition (2) is $180.12, and
condition (3) is $126. As the lowest of these three amounts is $126, payment must be made for this amount.
Based on this information, we decided that Medicare rules for coverage of the services have been met.
Therefore, we decided that the Plan has to pay $126 for the services provided on April 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to further pay for the emergency room services provided on September 21, 2020.

You asked the Plan to further pay for the services provided. You say that the enrollee felt that she had a medical condition of sufficient severity to seek emergency care. The Plan denied your request. The Plan says the documentation does not support the evaluation and management level as reported on the claim.

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. Usually, the presenting problem(s) are of high severity and require urgent evaluation by the physician.

We looked at the file and the rules. We find that CPT code 99285 is not supported in the medical record. The records show that the enrollee presented to the emergency room with abdominal pain when eating, which has been a slow growing problem of the past few months. The records do not indicate the enrollee presented with a problem of high severity. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to further pay for the emergency room services provided on September 21, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the lumbar/cervical spine.
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the requested MRI is medically necessary. The Plan denied your request. The Plan says that there is no documentation of a failure of a recent 6 week trial of a doctor prescribed therapy.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found given that this enrollee has failed conservative therapy sessions and continues to have concerning symptoms of lower extremity weakness associated with back pain, it would be medically appropriate to further evaluate the cause of her symptoms with MRI imagine of the spine. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the lumbar/cervical spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two provisional pontics (D6253 x2).
You asked the Plan to pre-approve the pontics. You say that you need these pontics to be approved. The Plan
denied your request. The Plan says this service is not covered under your benefit plan.
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 pre-approve two
provisional pontics (D6253 x2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nerve block.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your
request. The Plan says there is limited evidence about improved quality of life and impact of nerve blocks on
trigeminal neuralgia.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the block. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found you have a history of trigeminal neuralgia (TN) and your treating provider has requested coverage for a
SPG block. There is limited high quality literature available to support the proposed course of treatment. In this
setting, the requested service would be better defined as being investigational and/or unproven in nature, given
the need for further controlled studies. As such, this service would not meet the Medicare definition of medical
necessity.
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 block have not been met. Therefore, we decided that the Plan does not have
to pre-approve a nerve block.
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 25, 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 25, 2020.