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

We decided that the Plan does not have to pay for imaging services (procedure code 93308) provided to the enrollee on July 15, 2021.

You asked the Plan to pay for the sercies. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate modifier was not billed in this case.

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, we have confirmed that code 93308 is a column II code to column I code 33016. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code 93308) provided to the enrollee on July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided to the enrollee on June 15, 2021.

You asked the Plan to pay for the pneumatic compression device. You say that this was medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered by Medicare.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 

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, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided to the enrollee on June 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas device and vitamin injections (96372, 97112, J3490, J3411, J3415, J7999, 97016 and 97139) provided on August 23, 2021.
You asked the Plan to pay for the Sanexas device and vitamin injections. The Plan denied your request. The Plan says as non-covered services they are not a benefit when ordered by either a contracted or a non-contracted provider in any plan design.
The Plan must follow Medicare rules. Medicare rules state that in order for physician-provided drugs to be covered, the medical records must document the name of the drug administered as well as the dosage. The rules also say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas device and vitamin injections have not been met. Payment for Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes 96372 and J3490, J3411, J3415, J3490, and J7999 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. Additionally, review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. Therefore, we decided that the Plan does not have to pay for the Sanexas device and vitamin injections (96372, 97112, J3490, J3411, J3415, J7999, 97016 and 97139) provided on August 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray of the elbow provided on August
5, 2021.

You asked the Plan to waive the copayment for the x-ray of the elbow. You say that the services should be
covered as it was a part of your PCP visit. The Plan denied your request. The Plan says the cost-sharing applied
correctly based on the services provided.

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 $20
copayment for Outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $20 copayment for an x-ray of the elbow. The x-ray services are separate from
your primary care office visit. X-rays of the elbow fall 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 x-ray of
the elbow provided on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder detect test provided to the enrollee on July 21, 2021.

You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this service is not considered medically necessary and not cannot be approved.

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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this test has not been evaluated by the technical assessment process, and it is not covered. The service does not meet Medicare's criteria of being medically reasonable or 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder detect test provided to the enrollee on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy provided by a participating provider on January 5, 2021.

You asked the Plan to pay for endodontic therapy. You say that you would like this Plan to pay for this. The Plan denied your request. The Plan says the maximum allowance amount has already been met.

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 a $3,000 combined allowance for supplemental preventative and comprehensive dental services every year. 

We looked at the file and Medicare rules. The total amount you are being asked to pay is $1,447 which is less than the total amount of $1,553 due to reaching your maximum allowance amount of $3,000/ Based on this information, we decided that the Plan's rules for coverage of endodontic therapy have not been met. Therefore, we decided that the Plan does not have to pay for endodontic therapy provided by a participating provider on January 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) with computed tomography (CT) services.

You asked the Plan to pre-approve the PET/CT scan. You say that the requested study is being ordered for dementia and the clinical information provided supports its need. The Plan denied your request. The Plan says the notes sent do not meet the guidelines for coverage. The Plan says that the requested procedure is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that PET 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 PET/CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the records show that the enrollee's provider has ordered a PET/CT scan for the evaluation of dementia. The records did not support that enrollee met the diagnostic criteria of both AD and FTD at this time. The request is not otherwise being made for an oncologic indication. 

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 PET/CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) with computed tomography (CT) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing services (96133 x2 and 96138 x5).

You asked the Plan to pre-approve additional neuropsychology testing. You say that additional neuropsychological testing beyond what the Plan has approved is medically necessary. The Plan denied your request. The Plan says the additional testing services are not medically necessary and are considered excessive at this time.

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 additional neuropsychology testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Based on review of the records provided, it was noted that this patient's provider is asking for an excessive amount of the procedure beyond which is approved by LCD 33632. This patient has shown an impairment in functioning as documented. The patient has been showing difficulty with memory issues as outlined using the interpretation. There was no documentation that justifies the extra amount of time in the testing and assessment. Based on review the records provided in the information provided this patient does not meet the criteria for additional neuropsychological testing beyond which is approved by LCD 33632 based on the patient's clinical history and documentation presented.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional neuropsychology testing have not been met. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing services (96133 x2 and 96138 x5).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to the enrollee on May 26, 2021.

You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your request. The Plan says the services were not ordered by the doctor's office.

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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that cardiac risk assessment genetic screening testing was medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee's physician initiated the order for this testing.

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to the enrollee on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care visit you had on September 14, 2021.

You asked the Plan to waive the copayment for the primary care visit. You say that this as your annual wellness exam, so there should be no copayment. The Plan denied your request. The Plan says they contacted the provider who confirmed this was a new patient office visit, not an annual wellness visit. Therefore, the Plan says that the copayment was charged correctly.

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 $20 copayment for primary care visits. 

You have been asked to pay a $20 copayment for the primary care visit. The physician who provided this visit confirmed it was not an annual wellness exam. The billing also reflects that this was not an annual wellness exam, but an office visit to evaluate you for elevated blood pressure, prostate cancer screening, and elevated body mass index.

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 the primary care visit you had on September 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozurdex for the enrollee.
You asked the Plan to pre-approve Ozurdex. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the drug is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Ozurdex. Our reviewer says that Ozurdex is not medically reasonable and necessary for the enrollee. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Ozurdex. The enrollee has a diagnosis of unspecified retinal edema. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of Ozurdex in the enrollee's clinical situation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ozurdex have not been met. Therefore, we decided that the Plan does not have to pre-approve Ozurdex for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure device (E0601) and filter (A7038) provided on September 17, 2021.
You asked the Plan to pay for these items. You say that you were told the Plan would pay 80% for these items. The Plan denied your request. The Plan says that the items obtained by the member were rendered by a provider who is not under contract with the health plan and is not certified for Medicare.
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who is not enrolled in the Medicare Program. The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure device (E0601) and filter (A7038) provided on September 17, 2021.
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
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 need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from continued physical therapy, and occupational therapy, his rehab needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic testing services provided to the enrollee on
April 25, 2021.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says this service is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.

A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for molecular genetic testing
services provided to the enrollee on April 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) provided June 17, 2021.
You asked the Plan to pay for the office visit. You say that you are requesting the plan process payments accordingly. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202) provided June 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical cell stimulation (97032), neuromuscular reeducation (97112), and vasopneumatic device therapy (97016) provided on July 6, 2021.

You asked the Plan to pay for the outpatient therapy services. You say that the services were rendered to the enrollee in good faith. The Plan denied your request. The Plan says the services you received are not medically reasonable or necessary.

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 outpatient therapy services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the services rendered to the enrollee are considered experimental and investigational. Therefore, the reviewer found that the services were not medically reasonable or 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 the outpatient therapy services have not been met. Specifically, the services rendered are considered experimental and investigational. Therefore, we decided that the Plan does not have to pay for electrical cell stimulation (97032), neuromuscular reeducation (97112), and vasopneumatic device therapy (97016) provided on July 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that no photographs were provided to demonstrate the panniculus
hangs below the level of the pubis and the documentation does not support the enrollee experiences chronic
intertrigo.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The enrollee under
sleeve gastrectomy in 2016 and has had an 80 pound weight loss. The record indicates that the enrollee has a
diastases of the rectus muscle but no new hernia. The provided record does not indicate the pannus extends
below the level the pubic symphysis or that the enrollee has interitrgo refractory to conservative measures. The
record does not provide documentation of maintenance of a stable weight. Our physician reviewer found that
the enrollee's condition does not meet Medicare criteria for 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 not been met. Therefore, we decided that the Plan does not
have to pre-approve a panniculectomy for the enrollee.