Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the service necessary. The Plan denied your request. The Plan says there are not enough scientific studies to show that inserting a device to open the narrowed space would be safe and effective for the enrollee.

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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on December 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for a specialist office visit. You say that you would like this claim reprocessed and paid. You say that these services were provided by the member's primary care physician. The Plan denied your request. The Plan says there are in-network providers available for these services. The Play says that prior authorization was not obtained by the rendering facility.

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 a specialist office visit provided on December 17, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the periodontal maintenance (D4910) provided February 22, 2021.

You asked the Plan to provide additional payment for the periodontal maintenance. You say that the Plan documents are not clear that you would be charged extra for going to an OON dentist. The Plan denied your request. The Plan says since services were not provided by a network dental provider, you are responsible for the difference between the maximum allowable amount and the amount billed by the OON provider.

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. 

We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan has provided payment up to the Plan's contracted rate for the service. Therefore, we decided that the Plan does not have to provide additional payment for the periodontal maintenance (D4910) provided February 22, 2021.

Your complaint about potentially providing confusing or inconsistent information in some of their documents is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 July 23, 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 July 23, 2020.
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 the enrollee would greatly benefit from extensive physical and occupational therapy. The Plan denied your request. The Plan says the enrollee can safely receive the services needed in other settings.

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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care billed with DRG 872, provided on May 30, 2020, through May 31, 2020.

You asked the Plan to pay for inpatient hospital care billed with DRG 872. You say that the data and clinical evidence documented by the treating physicians supports A41 .9, Sepsis unspecified organism, as the principal diagnosis. The Plan denied your request. The Plan says the medical record did not support the diagnosis code of A41 .9, Sepsis unspecified organism, as the principal diagnosis.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with diagnosis code of A41 .9, Sepsis unspecified organism, as the principal diagnosis. 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 inpatient hospital care. Our reviewer says that DRG 872 is not supported by the medical records. Our physician reviewer found the medical records revealed insufficient objective clinical evidence to validate the diagnosis of sepsis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Specifically, the review has determined that sepsis was not present, and therefore, the DRG 872 is not supported. Therefore, we decided that the Plan does not have to pay for inpatient hospital care billed with DRG 872, provided on May 30, 2020, through May 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits for hemodialysis (99512) provided from January 4, 2021, to January 29, 2021.

You asked the Plan to pay for the home health services. You say that the services were pre-authorized by the enrollee's plan. You say that since they were authorized, they must be paid. The Plan denied your request. The Plan says the use of a non-Medicare certified facility is not a covered benefit of the enrollee's health plan.

The Plan must follow Medicare rules. Medicare rules say that payment cannot be made to providers who are not enrolled in Medicare.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Additionally, the record shows that the authorization for the services in this case specifically states that authorization does not guarantee that benefits will be paid. Therefore, we decided that the Plan does not have to pay for the home visits for hemodialysis (99512) provided from January 4, 2021, to January 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana (J7605).
You asked the Plan to pre-approve Brovana. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria.
The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Brovana. Our reviewer says that Brovana (J7605) is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug, Perforomist (Formoterol). Our reviewer also found that there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana (J7605).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide and a shower grab bar.
You asked the Plan to pre-approve a stair glide and a shower grab bar. You say that these items are medically necessary for your condition. The Plan denied your request. The Plan says these items are not covered.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. Medicare rules also say that for equipment to be covered, it must primarily serve a medical purpose. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. In addition, the shower grab bar in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a stair glide and a shower grab bar.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue-hard (bone, tooth) (D7285).
You asked the Plan to pre-approve the dental service. You say that you are in pain. You say that you cannot chew. You also say that you have cardiac conditions. The Plan denied your request. The Plan says incisional biopsy of oral tissue-hard is not listed as a covered service.
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 an incisional biopsy of oral tissue-hard (bone, tooth) (D7285).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on September 1, 2020.

You asked the Plan to waive the copayment for an MRI. You say that you disagree with how the claim was processed. 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 $0 copayment for mammography and ultrasounds and a $195 copayment for all other diagnostic and nuclear medicine radiological services.

You have been asked to pay a $195 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 September 1, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS system for the enrollee.

You asked the Plan to pre-approve these services. You say that the CardioMEMS System will allow you to better monitor and manage the symptoms that lead to repeat heart failure hospitalizations. The Plan denied your request. The Plan says that that this is not covered under the current Medicare Category B Investigational Device Exemption Requirements.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. The patient has NYHA Class III heart failure symptoms and is on multiple congestive heart failure (CHF) medications with recurrent and recent hospitalization for decompensated CHF. Management of his heart failure with full dose standard medical therapy and relying on weights, symptoms and signs has not been effective in keeping him with minimal symptoms and has resulted in acute hospitalizations. Cardiomems device monitoring in this situation can provide additional heart filling pressure data to better manage very complex diuretic and vasodilator regimens. Data from the Champions trial along with longer term follow-ups studies have shown a significant decrease in hospitalizations and improvement in heart failure symptoms and NYHA Class with the use of this device. There is also published expert opinion in the cardiology literature as to its appropriate use, as well as reasonable patient selection criteria, and FDA approved indications, all of which are met in this clinical instance. Given the severe symptoms of recurrent CHF which appears very sensitive to volume loading conditions, complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this patient, use of the Cardiomems device is reasonable and has clinical data, expert opinion, and approved FDA indications to support its use in selected appropriate clinical situations like this one. It would not be considered investigational for these indications. Our physician reviewer found that the enrollee's condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMS system for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided by an out-of-network
provider on June 5, 2020.

You asked the Plan to pay for the nursing facility visit. You say that the physician depends on the hospital staff
to verify eligibility and to obtain the proper authorization. You say that the physician provided medically
necessary services and the claim should be paid at the maximum amount allowed. The Plan denied your
request. The Plan says the services are not authorized because the provider is a non-network provider with the
Plan.

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 nursing facility visit provided by an out-ofnetwork
provider on June 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power scooter (CPT code K0800).

You asked the Plan to pre-approve the power scooter. You say that the scooter is needed for the inside and outside. The Plan denied your request. The Plan says you need an evaluation first.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power scooter have not been met. You need an evaluation first and the Plan has authorized that. The evaluation will tell the Plan if the power operated scooter is necessary for you to perform activities of daily living; whether you can operate a power operated scooter safely and whether it will fit within your house. These are the coverage requirements for Medicare. If the scooter is necessary for you to perform your mobility related activities of daily living, the evaluation will tell the Plan that, and will tell the Plan what needs to be included in the scooter. If the power operated scooter evaluation determines that you meet the Medicare requirements then this will be requested with the specific type of power scooter for review by your medical group. Therefore, we decided that the Plan does not have to pre-approve the power scooter (CPT code K0800).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found notes from home health last month said that the enrollee needs a cane to move about. The home health nurse said that the enrollee was "noncompliant" with taking medications as prescribed. There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate caret home with home with services. The enrollee does not require services at the LTACH. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.