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

We decided that the Plan does not have to pay for the Guardant360 testing provided to the enrollee on August
30, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the coverage criteria are
not met.
The Plan follows Medicare rules. Medicare rules say that Guardant360 testing is covered when the criteria
established in the applicable LCA are met.
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 Guardant360 testing is not medically reasonable and necessary in this case. Our physician reviewer
found that per the LCA, the patient must not have been previously tested using the same NGS test for the same
primary diagnosis of cancer or repeat testing with the same diagnosis. Repeat testing would only be covered
when a new primary cancer diagnosis is made by the treating physician. The requested Guardant360 testing is
not medically reasonable and necessary according to the coverage criteria established in the above LCA.
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 Guardant360 testing provided to the enrollee on August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two core buildups, including any pins when required (D2950 x2), endodontic therapy (D3310), maxillary partial denture (D5225), interim partial denture (D5820), and bone replacement graft for ridge preservation (D7953) provided from April 18, 2020, to May 11, 2020 by an OON provider.
You asked the Plan to pay for the core buildup, endodontic therapy, maxillary partial denture, interim partial denture, and bone replacement graft. You say that you would like to appeal these services. The Plan denied your request. The Plan says the core buildup, maxillary partial denture, interim partial denture, and bone replacement graft are not covered.
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 the two core buildups, including any pins when required (D2950 x2), endodontic therapy (D3310), maxillary partial denture (D5225), interim partial denture (D5820), and bone replacement graft for ridge preservation (D7953) provided from April 18, 2020, to May 11, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator (K0606).
You asked the Plan to pay for the automatic external defibrillator. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was filed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the automatic external defibrillator was not filed until November 30, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator (K0606).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the
enrollee on August 6, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the records do not support the services 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.

We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the
CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a
place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have
not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS
G0483) provided to the enrollee on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve blocks (64624, 99152).

You asked the Plan to pre-approve genicular nerve blocks. You say that you need the referral to be approved so you'd like to appeal. You are in constant pain and really needs the services that your pain management doctor is requesting for you. The Plan denied your request. The Plan says this type of treatment is considered experimental and investigational as it is not yet proven to be useful or effective and not widely accepted by the medical field.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve blocks (64624, 99152).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre.
You asked the Plan to pre-approve a Freestyle Libre. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
Freestyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Freestyle Libre.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided December 30, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like to consider this claim for medical necessity. The Plan denied your request. The Plan says the submitted documentation did not include proof of delivery or a delivery ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery. In this case, there is no proof of delivery demonstrating the item was delivered to the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (J0178) provided January 25, 2021.
You asked the Plan to pay for the injections. You say that the injections were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowable amount.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code J0178 is 4. You billed 8 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (J0178) provided January 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Fulphila (Q5108).
You asked the Plan to pre-approve Fulphila. You say that the requested treatment is a medical necessity for the
enrollee. The Plan denied your request. The Plan says the requested use is not medically accepted.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 Fulphila. Our reviewer says that the
requested treatment is not medically necessary. Our physician reviewer found that the enrollee has
myelodysplastic syndrome (MDS) and is on oral Decitabine and cedazuridine with Neulasta. The requested use
of Fulphila is not FDA-approved for the enrollee's diagnosis. Fulphila is not indicated in myeloid malignancies
of which MDS is a precursor. The use is not supported by one of the major drug compendia or by clinical
research that appears in a Medicare-approved medical journal. The drug compendia recommend dose reduction
with Decitabine and cedazuridine.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have
to pre-approve treatment with Fulphila (Q5108).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services (S9379) provided on December 8, 2020, through December 22, 2020.
You asked the Plan to pay for the home infusion therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9379 has a status indicator of I and 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. We find that CPT code S9379 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9379 has a status indicator of I. This means that CPT code S9379 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services (S9379) provided on December 8, 2020, through December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions of four or
more teeth or tooth spaces per quadrant and alveoloplasty in conjunction with extractions of one to three teeth
or tooth spaces per quadrant provided on December 1, 2020.

You asked the Plan to pay for the alveoloplasties in conjunction with extractions. You say that you would like
to appeal these services. The Plan denied your request. The Plan says these services are not covered under your
dental plan. The Plan also says that you signed a treatment plan with the provider acknowledging and accepting
financial responsibility prior to receiving these services.

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 the
alveoloplasty in conjunction with extractions of four or more teeth or tooth spaces per quadrant and
alveoloplasty in conjunction with extractions of one to three teeth or tooth spaces per quadrant provided on
December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel provided on November 9, 2020.

You asked the Plan to pay for the Tempus Gene Panel. 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 the same test was provided on November 5, 2020 that the Plan paid for.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that the Tempus Gene Panel was provided on November 9, 2020. We are unable to determine if Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel provided on November 9, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a scleral lens (V2531).
You asked the Plan to pre-approve a scleral lens (V2531). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that scleral lenses are only covered for certain conditions.
We looked the file and Medicare rules. Medicare covers scleral lenses for the treatment of an eye rendered sightless and shrunken by inflammatory disease or for the treatment of "dry eye" where the scleral lens serves as a substitute for the function of the diseased lacrimal gland. When a scleral lens is used to treat any other condition, it is excluded from coverage. In this case, the request for a scleral lens is to treat the enrollee's keratoconus, a condition in which the clear tissue on the front of the eye (cornea) bulges outward. Based on this information, we decided that Medicare rules for coverage of a scleral lens (V2531) have not been met. Therefore, we decided that the Plan does not have to pre-approve a scleral lens (V2531).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the provisional splinting (D4321) provided on October 21, 2020.
You asked the Plan to pay for the provisional splinting. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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 the provisional splinting (D4321) provided on October 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided May 15, 2021.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.
The Plan follows Medicare rules. Medicare rules say that the lumbar-sacral orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically necessary and reasonable. Our physician reviewer found the records indicate that the enrollee has rheumatoid arthritis and low back pain. The record does not indicate that the enrollee has had a recent surgical procedure or injury to the spine or related soft tissue. While the record does include a subjective description of pain and the need for support it does not provide credible evidence of a subjective assessment as required by Medicare rules. 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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided May 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone graft at time of implant placement (D6104) and sinus augmentation with bone or bone substitutes (D7951).

You asked the Plan to pre-approve the bone graft and sinus augmentation. You say that the bone graft is medically necessary in order for your dentist to complete the implant. The Plan denied your request. The Plan says these services are not covered under your benefit plan.

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 pre-approve a bone graft at time of implant placement (D6104) and sinus augmentation with bone or bone substitutes (D7951).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for personal care services (T1019U6) provided August 3, 2020.

You asked the Plan to pay for the personal care services. You say that the services were medically necessary. The Plan denied your request. The Plan says home services that provide assistance with personal hygiene, dressing, feeding, and nutritional support are not a covered benefit.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 

The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for personal care services (T1019U6) provided August 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intracept procedure (CPT code(s): C9752, C9753, 22899), for the enrollee.
You asked the Plan to pre-approve the services. You say that the procedure is not a soft tissue ablation, it is performed with the vertebral body to ablate the basivertebral nerve. The Plan denied your request. The Plan says the services are 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental for the treatment of back pain. More research is needed to show safety and efficacy of the procedure. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve intracept procedure (CPT code(s): C9752, C9753, 22899), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system any
type (CPT code E2300).
You asked the Plan to pre-approve the seat. You say that the seat is necessary. The Plan denied your request.
The Plan says the seat is non-covered because they are not primarily medical in nature.
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 wheelchair accessory, power seat elevation system any type
(CPT code E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 00532 provided on June 23, 2020.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 00532 is anesthesia for access to central venous circulation. We find that CPT code 00532 is not supported in the medical record. Specifically, a claim was submitted and paid for the same procedure code by the same tax identification number. This means that this is a duplicate claim. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00532 provided on June 23, 2020.