Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network
provider.
You asked the Plan to pre-approve the physical therapy. You say that you have a vacation home in one state,
and you do not have anyone to assist taking care of you in your home state. You say that you do not want to be in
in your home state due to high COVID-19 numbers. The Plan denied your request. The Plan says your knee surgery
is an elective procedure, and physical therapy is also not urgent or emergent.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical
therapy to be provided by the requested out-of-network provider.
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. The Plan denied your request. The Plan says based on Medicare guidelines the requested services do not meet the requirements for approval.
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, 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 (ex. skilled nursing facility/sub-acute rehab). 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for the continuous glucose monitor provided by an out-of-network provider on January 4, 2021.
You asked the Plan to pay for the supply allowance for the continuous glucose monitor. You say that you did not know pre-authorization was needed for this member. You say that the service was medically necessary and should be processed for payment. The Plan denied your request. The Plan says in-network providers were available.
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 supply allowance for the continuous glucose monitor provided by an out-of-network provider on January 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left knee arthroscopy.
You asked the Plan to pre-approve arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) (29877). You say that the procedure is necessary for pain relief. The Plan denied your request. The Plan says the degree of arthritis on the enrollee's MRI is too advanced to support the requested service.
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 arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) (29877). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the imaging studies show advanced knee degenerative joint disease (DJD). Knee arthroscopy is not effective in cases of advanced knee (DJD). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) (29877) have not been met. Therefore, we decided that the Plan does not have to pre-approve left knee arthroscopy.
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 21, 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 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the enrollee has has demonstrated failure of conservative treatments and also has characteristics that preclude use of a simple, non-segmented device. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on
December 15, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
service.

The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels,
except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or
documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.

We looked at the file and Medicare rules. Per LCD L36358, the requested risk assessment panel is not a
covered service. Based on this information, we decided that Medicare rules for coverage of the testing have not
been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel
provided on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the walk-in tub, including installation (A9270).

You asked the Plan to pre-approve the walk-in tub. You say that you have several degenerative conditions that
are preventing you from properly bathing yourself and having a walk-in tub will be much safer. The Plan
denied your request. The Plan says this item is not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue 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 the walk-in tub, including installation (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Trilogy home ventilator.

You asked the Plan to pre-approve a ventilator. You say that the enrollee has failed BiPAP and requires Trilogy. The Plan denied your request. The Plan says the use of a ventilator is denied without documentation of set volume settings.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 ventilator. Our physician reviewer found that in this case, the enrollee has severe chronic obstructive pulmonary disease with chronic hypercapnic respiratory failure. The enrollee was most recently treated with BiPAP and 3 liters nasal canula. The required settings can be achieved with available BiPaP machines that include adapto-servo technology. The trilogy ventilator would exceed the capabilities of what are medically reasonable and necessary as defined by Medicare rules. Therefore, the requested service cannot be recommended.

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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a Trilogy home ventilator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.

You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the enrollee has not tried and failed Orthovisc and Monovisc.

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 Durolane. Our physician reviewer found that the enrollee has pain related to osteoarthritis of the right knee, confirmed with imaging studies. He has failed conservative treatment. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The enrollee has not tried and failed the required drugs. There is no indication that the plan's required drugs would likely be less effective 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
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 this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.
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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You were admitted for abdominal pain. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the
unspecified preventive service (D1999) provided on February 2, 2021.

You asked the Plan to pay for the dental services. You say that you were dissatisfied with your previous dentist.
You say that they were very unprofessional. You say that you had to find a new dentist. You also say that the
services should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is
covered every 3 plan years. The Plan also says that the frequency limit 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 and the service is listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation
that you received on October 6, 2020. Additionally, the Plan contacted the provider's office and verified that
you were not billed for service D1999. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation (D0150) and the unspecified preventive service (D1999) provided on February
2, 2021.