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

We decided that the Plan does not have to pre-approve Xiaflex.
You asked the Plan to pre-approve Xiaflex. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not covered.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. In addition, we note that this drug is a very high cost drug on a specialty tier and you have requested a tiering exception. Tier exceptions are not available for drugs covered by Part B. Therefore, we decided that the Plan does not have to pre-approve Xiaflex.
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 30, 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 30, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Dexcom G6 Transmitter.
You asked the Plan to pre-approve a Dexcom G6 Transmitter. You say that this item is medically necessary. The Plan denied your request. The Plan says that the patient has not tried the Plan's preferred brand.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the case file did not include medical records to support the request for the Dexcom G6. As a result, we asked the Plan to reach out to your provider for medical records that support the request for this specific brand. We did not receive a response for this request or why the Plan was unable to obtain these medical records. Therefore, we decided that the Plan has to pre-approve a Dexcom G6 Transmitter.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for osseous surgery (D4260) provided on January 27, 2021.
You asked the Plan to pay for osseous surgery. You say that the service was medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 pay for osseous surgery (D4260) provided on January 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on February 17, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was not billed with an appropriate primary diagnosis code. 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 pay for the occupational
therapy services rendered on February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the insertion of a heart rhythm monitor and an ECG provided on November 10, 2020.
You asked the Plan to waive the copayments for the insertion of a heart rhythm monitor and an ECG. You say that you cannot afford the charges. 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 $270 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan also clearly says that you must pay a $20 copayment for diagnostic tests. You received the insertion of a heart rhythm monitor on November 10, 2020. The insertion of a heart rhythm monitor is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $270 copayment. You received an ECG on November 10, 2020. Therefore, you are responsible to pay the $20 copayment. The total amount you owe is: $290. You have been asked to pay the total copayment amount of $290 for the insertion of a heart rhythm monitor and an ECG. The insertion of a heart rhythm monitor falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. An ECG 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 copayments for the insertion of a heart rhythm monitor and an ECG 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 December 17, 2020.You asked the Plan to pay forthe 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 December 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bed rails.
You asked the Plan to pre-approve bed rails. The Plan denied your request. The Plan says the side rails are covered as part of a covered hospital bed.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The file shows that side rails were requested to be used on a non-hospital bed. We looked at the file and the rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. The requested side rails are not being used as part of a covered hospital bed.
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve bed rails.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis.
You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says there is no evidence of prior imaging with an ultrasound.
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 CT scan. Our physician reviewer found that the enrollee has had abdominal pain intermittent with radiation to the back for 2 years. There is no specific clinical rationale for the requested CT scan. There are no reported physical exam abnormalities or lab abnormalities. There is no history of diarrhea or melena. Other testing modalities, such as fecal occult blood/abdominal ultrasound, or a urinalysis have not been obtained prior to the requested CT scan. The review has determined that the requested CT Scan is 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided on February 11, 2020.
You asked the Plan to waive the coinsurance for the Part B drugs. You say that you had outpatient kidney stone surgery and should have a $0 copayment for this procedure. 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the cost for Medicare Part B chemotherapy drugs and other Medicare Part B drugs.
You have been asked to pay $323.75 which is 20% of the allowed amount for the Part B drugs. The allowed amount is $1,618.75. ($1,618.75 x 20% = $323.75). The Part B drugs falls within the "Medicare Part B prescription 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 Part B drugs provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on January 19, 2021.
You asked the Plan to pay for the psychotherapy. You say that the service was medically necessary. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization and 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 psychotherapy provided by an out-of-network provider on January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional features for a prosthetic leg (L5968, L5981).
You asked the Plan to pre-approve the features. You say that this is medically necessary. The Plan denied your request. The Plan says the requested K3 components exceed medical need.
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 features. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to Medicare, additional features or components to a prosthesis may be necessary depending on your potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating practitioner, considering multiple factors. In this case, the documentation doesn't support that you require the requested advanced foot with ankle to accomplish a K3 prosthesis. You have a right knee contracture that is likely to limit ambulation and the approved prosthesis should be sufficient for your functional requirements. 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 features have not been met. Therefore, we decided that the Plan does not have to pre-approve additional features for a prosthetic leg (L5968, L5981).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an EGD provided on January 28, 2021.
You asked the Plan to waive the deductible for an EGD. You say that you were not aware that you would owe a deductible. 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. Your contract with the Plan says that there is a $1,000 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received an EGD on January 28, 2021. The record shows that you had not met the $1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $137.90.
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time an EGD was received on January 28, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an EGD provided on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (L8702).
You asked the Plan to pre-approve the MyoPro Motion G Orthotic device. You say that this item is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this item is considered experimental and investigational.
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 MyoPro Motion G Orthotic device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.
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 MyoPro Motion G Orthotic device have not been met. Therefore, we
decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device (L8702).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 30, 2020.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 87150 and 87186 are not supported.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 87150 is culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. The definition of code 87186 is susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-antimicrobial, per plate.
We find that CPT codes 87150 and 87186 are not supported in the medical record. Specifically, the records do not contain results to support culture and typing by nucleic acid probe to support code 87150. There is no documentation to support susceptibility studies per plate to support code 81786. 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 pay for the laboratory services rendered on November 30, 2020.