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

We decided that the Plan does not have to waive the co-payment for the ophthalmic ultrasound provided on
October 21, 2020.

You asked the Plan to waive the co-payment for the ophthalmic ultrasound. You say that according to your
benefits, you should have a $0 co-payment. You say this charge related to cataract surgery should be covered.
The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $105
co-payment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a freestanding facility (such as a radiology center or medical clinic). For this date of
service, you have been asked to pay the allowed amount of the claim because this amount is less than the
standard $105 co-payment for the ophthalmic ultrasound.

You have been asked to pay a $69.35 co-payment for the ophthalmic ultrasound. The ophthalmic ultrasound
falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The
record shows you were charged for the ultrasound in addition to the office visit. 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 co-payment for the ophthalmic ultrasound provided on October 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the crown - porcelain fused to high noble metal (D2750) received October 6, 2020 from the out-of-network provider.

You asked the Plan to waive the coinsurance for the crown. You say that you do not have a dentist close by that is in the plan's network. The Plan denied your request. The Plan says the correct cost share applied to the claim.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for crowns, inlays, and onlays. The Plan contract also states that you may be billed more by an out-of-network provider if the charge is greater than the maximum allowable charge.

You have been asked to pay 50% coinsurance, plus the difference between the Plan's maximum allowable charge and what was charged by the out-of-network provider for the crown (The amount billed by the out-of-network provider = $1,035; the Plan's maximum allowable charge = $585.00; 50% coinsurance for the maximum allowable charge = $292.50; the difference between the MAC and what was charged by the OON provider = $450; $292.50 + $450 = $742.50). The crown falls within the crowns, inlays, and onlays 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 coinsurance for the crown - porcelain fused to high noble metal (D2750) received October 6, 2020 from the out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the cervical spine for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records do not show that an MRI is contraindicated.

The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has had a prior cervical fusion, ACDF C3-7 which was not recognized by the plan. The records do not include the MRI report from 4/15/21. Likewise, x-rays of the cervical spine are referenced as showing possible pseudoarthrosis at C4-5, but there is no report in the chart. Finally, the actual order is for a CT cervical myelogram rather than a routine CT of the cervical spine without contrast. Obviously, the medical necessity of the ordered CT cervical myelogram is possible based upon the incomplete information provided however a firm determination cannot be made without the benefit of a correct order as well as reports from prior imaging exams.

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the cervical spine for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutritional counseling (S9470) provided on February 9, 2021 and February 23, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have exceeded the allowable benefit for this service.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.
Records do not show that you suffer from renal disease or diabetes. Although Medicare coverage criteria are not met, the Plan elected to cover two visits for this service according to its internal policy which allows two visits per year.
Additionally, there is nothing indicated in your contract which would require the Plan to cover more than these two visits. Therefore, we decided that the Plan does not have to pay for the nutritional counseling (S9470) provided on February 9, 2021 and February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a second pair of eyeglasses (V2020, V2799, V2750, V2784) provided on November 10, 2020.

You asked the Plan to pay for the eyeglasses. You say that you saw a Plan-preferred provider for these glasses and would like additional reimbursement. The Plan denied your request. The Plan says there is a maximum annual allowance of $315 that may be used for eyewear. You purchased two pairs of glasses. The Plan covered the first in full, but once you met your $315 allowance, you were responsible for the remaining cost of the eyewear.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eyewear up to $315 per year.

We looked at the file and the Plan's rules. Documentation shows that the Plan covered the first $315 for the two pairs of glasses, and you are left responsible for the remainder of the cost. This is appropriate based on the Plan's rules as described in the contract. Therefore, we decided that the Plan does not have to pay for a second pair of eyeglasses (V2020, V2799, V2750, V2784) provided on November 10, 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 September 1, 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
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. The HCPCS/CPT Code Manual definition of code J1955 is injection, levocarnitine, per 1 gm.

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, J1955, 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 September 1,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for PhotoBioModulation therapy (D9430) and unspecified preventative procedure (D1999) provided from September 3, 2020, to October 1, 2020.

You asked the Plan to pay for PhotoBioModulation therapy. You say that this was a necessary service that is medical in nature and should be covered by the Plan. The Plan denied your request. The Plan says this service is dental in nature and medical records indicate that this service was provided to treat tooth pain and issues with the structures directly supporting the teeth. This service is not covered by Medicare and the Plan does not offer supplemental dental benefits.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for PhotoBioModulation therapy (D9430) and unspecified preventative procedure (D1999) provided from September 3, 2020, to October 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an echocardiography (93306) provided November 23, 2020.

You asked the Plan to waive the co-payment for the echocardiography. You say that the co-payment was always $20 in past. The Plan denied your request. The Plan says the correct co-payment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 co-payment for diagnostic tests.

You have been asked to pay a $90 co-payment for the echocardiography. The echocardiography falls within the diagnostic tests 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 co-payment for an echocardiography (93306) provided November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Caris MI Profile testing (81455) provided on October 18, 2020.
You asked the Plan to pay for the Caris MI Profile testing. You say that you would like reconsideration because this testing is covered by Medicare and medically necessary. The Plan denied your request. The Plan says This testing is not a part of Palmetto GBA's library and therefore is not FDA approved for this lab.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Caris MI Profile testing have not been met. Specifically, this testing has not been evaluated through the application process and/or technical assessment. This testing does not appear on the MoIDX library and is therefore not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pay for the Caris MI Profile testing (81455) provided on October 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric scooter.

You asked the Plan to pre-approve an electric scooter. You say that the requested device is medically
necessary. The Plan denied your request. The Plan says an electric scooter is non-covered for use outside of
home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve an electric scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for inpatient hospital care provided April 6, 2020 to April 15, 2020.

You asked the Plan to waive the co-payment for the inpatient hospital care. You say that the co-payment should be waived. The Plan denied your request. The Plan says the correct co-payment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350.00 per day co-payment for Days 1 through 5 of inpatient care.

You have been asked to pay a $350.00 per day co-payment for the first 5 days of a 9-day inpatient stay, for a total of $1,750. 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 co-payment for inpatient hospital care provided April 6, 2020 to April 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen equipment purchased on July 16, 2020.

You asked the Plan to pay for the purchased oxygen equipment. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the denial of payment for this
item is correct because purchased oxygen equipment is not covered.

The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for
coverage and purchased oxygen equipment is statutorily non-covered.

We looked at the file and Medicare rules. This item is not reimbursable when purchased. Based on this
information, we decided that Medicare rules for coverage of the purchased oxygen equipment have not been
met. Therefore, we decided that the Plan does not have to pay for the oxygen equipment purchased on July 16,
2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that it does not appear you are in need of therapy at the level of intensity that requires a skilled nursing facility.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) 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 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. The HCPCS/CPT Code Manual
definition of code J1955 is injection, levocarnitine, per 1 gm.

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, J1955, 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.