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

We decided that the Plan does not have to pay for the Sanexas NeoGen therapy with Nutri-Pharmaceutical blend injections (99212, 97112, 97032, 97016,96372, J3490, J3420, J3415 and J3411) provided on March 1, 2021.
You asked the Plan to pay for the Sanexas NeoGen therapy with Nutri-Pharmaceutical blend injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the clinical value and effectiveness of electrical cell stimulation and the subcutaneous injection of FDA Nutri-Pharmaceutical blend in the setting of chronic pain and paresthesia have not been demonstrated in the peer-reviewed literature.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas NeoGen therapy with Nutri-Pharmaceutical blend injections have not been met. Specifically, 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 Arizona. Additionally, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Finally, the office visit at issue was billed with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management (EM) service by the same physician or other qualified health care professional on the same day of a procedure or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to the treatment provided to the enrollee on this date of service. Therefore, we decided that the Plan does not have to pay for the Sanexas NeoGen therapy with Nutri-Pharmaceutical blend injections (99212, 97112, 97032, 97016,96372, J3490, J3420, J3415 and J3411) provided on March 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 6, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. The file shows that the enrollee was treated as inpatient on dates of service November 9, 2020 through November 11, 2020. The laboratory services provided in this case were included in the inpatient payment. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the care can be received in another setting, such as home, a long-term care facility, or other outpatient setting.

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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing or skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, custodial and therapeutic, as a practical matter, can be provided 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the lenses provided on February 3, 2021.

You asked the Plan to pay more for the lenses. You say that you received a notice that you met your deductible
and the total you will be billed is $0. You say that you are appealing the denial of payment. The Plan denied
your request. The Plan says the maximum allowance of $150 was paid.

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 up to $150 every 24 months for eyewear.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the lenses have not been met. Specifically, the Plan paid the maximum allowance of $150 toward
this purchase. Therefore, we decided that the Plan does not have to pay more for the lenses provided on
February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the over-the-counter items purchased on June 5, 2021.

You asked the Plan to pay for the over-the-counter items. You say that there was still a balance left on your card at the time of the purchase. You say that there could be an issue with the system that is misidentifying your benefits as being exhausted. The Plan denied your request. The Plan says the items purchased exceeded the benefit limit of $112 per calendar quarter.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the over the counter items is an OTC item. Therefore, we decided that the Plan does not have to pay for the over-the-counter items purchased on June 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve autologous soft tissue grafting.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has Treacher Collins syndrome with severe micrognathia and Pruzansky 3 mandibular deformity, with resultant problems with malocclusion, difficulty chewing, and difficulty breathing/upper airway obstruction. It is noted that she has a forehead deformity from likely resorption of a prior bone graft. The note dated August 18, 2021 states that the issue that bothers her most is her forehead, with complaints of "depression that often gives her headaches and is worried about a communication to her neural structures." The records support that the requested autologous fat grafting to the forehead would be cosmetic in nature. It is not demonstrated that the surgery would be to correct or improve a functional problem. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve autologous soft tissue grafting.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation therapy provided on January 27, 2021.

You asked the Plan to pay for the electrical stimulation therapy. The Plan denied your request. The Plan says the billed code is not valid for Medicare purposes.

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 97014 is application of a modality to 1 or more areas; electrical stimulation (unattended). 

We find that CPT code 97014 is not supported in the medical record. Specifically, CPT code 97014 has a status indicator of I. This means that CPT code 97014 is not valid for Medicare purposes.

Based on this information, we decided that Medicare rules for coverage of the electrical stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation therapy provided on January 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays rendered on May 18, 2021.

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 codes 75716 and 75774 are not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 37225 (endovsacular revascularization), 75716 (bilateral extremity angiography), and 75774 (selective angiography). Codes 75716 and 75774 are column II codes with a modifier indicator of 1 when billed with column I code 37225. Codes 75716 and 75774 were not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the x-rays rendered on May 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician services provided on June 24, 2020.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says that the provider needs to bill correctly for these services.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for these services by a contract provider. The file does not show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means these services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for physician services provided on June 24, 2020.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for inpatient rehabilitation services you received from March 11, 2021, to March 23, 2021.

You asked the Plan to reduce the copayment for the inpatient rehabilitation services. You say that you are being overcharged for these services because the facility was a skilled nursing facility, not an inpatient rehabilitation facility. The Plan denied your request. The Plan says you were charged this copayment 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 $403 copayment per day for days 1-5 and a $0 copayment per day for days 6 and beyond for inpatient hospital services, including inpatient rehabilitation.

You have been asked to pay a $403 copayment per day for days 1-5 and a $0 copayment per day for days 6 and beyond (for a total of $2015) for the inpatient rehabilitation services. The medical records from this stay confirm that you were in an acute inpatient rehabilitation stay, not in a skilled nursing facility. 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 reduce the copayment for inpatient rehabilitation services you received from March 11, 2021, to March 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient psychiatric admission for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the inpatient criteria is not met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found based on a review of the records provided, it is not expected that this enrollee would improve in a reasonable period of time as she did not have dangerousness to self or others, auditory or visual hallucinations or behaviors threatening acute safety. She was cooperative and compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. The health plan's denial of inpatient psychiatric services appears appropriate.

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric admission for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.
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 based on the medical records provided, 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 do not require an intensive rehabilitation program. There is no documentation that you
require the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the orthopedic surgery office visit and the Betamethasone acetate injection you received on June 1, 2021, and the orthopedic surgery office visit and the Monovisc injection you had on June 28, 2021.

You asked the Plan to waive the cost sharing for the specialist visits and the injections. You say that you do not believe you should have to pay this cost sharing because you did not receive any treatment that helped you. You also stated that you cannot afford this cost sharing. The Plan denied your request. The Plan says you were charged this cost sharing 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 $30 copayment for specialist visits and 20% coinsurance for Medicare Part B drugs.

You have been asked to pay a $30 copayment for the specialist visits and 20% coinsurance for the injections. These cost sharing amounts apply regardless of your satisfaction with the services received. 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 cost sharing for the orthopedic surgery office visit and the Betamethasone acetate injection you received on June 1, 2021, and the orthopedic surgery office visit and the Monovisc injection you had on June 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on April 19, 2021 by a non-participating provider.
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 the services were rendered by a non-participating provider without prior authorization.
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 nursing facility care provided on April 19, 2021 by a non-participating provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection you received on March
26, 2021.

You asked the Plan to waive the coinsurance for the Prolia injection. You say that you feel as though you are
being overcharged for this medication because you said you already paid a $60 copayment. The Plan denied
your request. The Plan says you were charged this coinsurance correctly. The Plan stated that there is no claim
on file showing a $60 copayment, but you were charged coinsurance.

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 20%
coinsurance for Medicare Part B drugs.

You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the
Medicare Part B drugs 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 Prolia
injection you received on March 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 14, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 11. However, the records do not show that the specimen was collected in an office setting. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with power options, accessories, and seating components.

You asked the Plan to pre-approve Group 3 power wheelchair. You say that you have multiple conditions that significantly decrease your mobility. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you do not have a condition for which a Group 3 power wheelchair may be covered.

The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.

The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Because you do not meet the criteria for the base Group 3 power wheelchair, the related accessories are also denied. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with power options, accessories, and seating components.