Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140).

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says you have exceeded the allowable frequency
limit for this dental 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.

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of this service have not been met. Specifically, the Plan covers a limited oral examination once per
plan year. You previously received this service, which was paid for by the Plan. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound.

You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges and
would not have had the ultrasound if it were not necessary. 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 $300
copayment for ultrasounds.

You have been asked to pay the allowed amount of $115.91, which is less than the $300 copayment for an
ultrasound. An ultrasound 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 copayment for an ultrasound.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation of portable x-ray equipment (R0070).

You asked the Plan to pay for the diagnostic services. You say that as a mobile physician office outfitted with x-ray equipment, you met the requirement of transporting x-ray equipment to the location where services were performed. The Plan denied your request. The Plan says place of service inappropriate for procedure.

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 R0070 is Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen. 

We find that CPT code R0070 is not supported in the medical record. Specifically, CPT code R0070 has a Professional Component (PC)/Technical Component (TC) indicator of 3 per the 2020 National Physician Fee Schedule Relative Value File July Release. Based on this information, we decided that Medicare rules for coverage of the diagnostic se4rvices have not been met. Therefore, we decided that the Plan does not have to pay for transportation of portable x-ray equipment (R0070).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the
services are medically necessary. Our physician reviewer found although the member does not have any skilled
nursing needs, they have had a significant decline in physical functioning. The member does require skilled
therapy services on a daily basis at a skilled nursing facility to restore function and avoid further decline or
complications. Admission to a skilled nursing facility for inpatient rehab services is medically 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 SNF care have been met. The Plan must continue coverage for the SNF skilled
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing
facility (SNF) care.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device.

You asked the Plan to pay for a pneumatic compression device (E0676). You say that you are unable to obtain prior authorization due to the nature of the equipment. The Plan denied your request. The Plan says this device is not covered for prophylaxis at home.

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.

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. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on July 5, 2019.

You asked the Plan to pay for practitioner visit. You say that you did not receive proper notice of the enrollee's benefit determination, hence the untimely submission of the claim. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.

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 practitioner visit was not filed until September 18, 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 a practitioner visit provided on July 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on June 18, 2020.You asked the Plan to pay for the paramedic intercept services. You say that these services were medically necessary.The Plan denied your request. The Plan says that paramedic intercept services are not covered.The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that the provider does not have a contract with the volunteer ambulance company that provided the transport services.Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing (D0270).

You asked the Plan to pay for the bitewing. You say that you would like to appeal this service. The Plan denied your request. The Plan says the frequency limit for this service has been exceeded.

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, bitewing x-rays are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0274) and your bitewings benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing (D0270).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on October 12, 2020.

You asked the Plan to pay for the extraction. You say that due to the preventative measure to a medical consequence, 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 extraction (D7140) provided on October 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TESTOPEL.

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. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found there are no submitted records for
review. A submitted laboratory result shows a normal testosterone level. There is no evidence that the enrollee
has hypogonadism, delayed puberty or current testosterone therapy (to explain the normal laboratory result).
As such, the requested testosterone is not shown to be medically necessary or reasonable.

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 TESTOPEL.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mobile x-ray services (Q0092, R0070).

You asked the Plan to pay for the mobile x-ray services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are not eligible for separate payment.

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 Q0092, & R0070 is not supported in the medical record. Specifically, payment for these services are included in the Part A SNF stay. These services are not separately billable. Based on this information, we decided that Medicare rules for coverage of the mobile x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for mobile x-ray services (Q0092, R0070).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric diagnostic evaluation (90792).

You asked the Plan to pay for psychiatric diagnostic evaluation. You say that your physician provided medically necessary services to the enrollee in good faith. In consideration for the services rendered, you feel your doctor is entitled to reimbursement. The Plan denied your request. The Plan says this claim was received past the timely filing limit.

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 psychiatric diagnostic evaluation was not filed until September 14, 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 psychiatric diagnostic evaluation (90792).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Avastin.

You asked the Plan to pre-approve Avastin. You say that the medication is necessary. The Plan denied your
request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Avastin. Our reviewer says that the
medication is necessary. Our physician reviewer found intravitreal Avastin may be used as adjunct to
brachytherapy as it reduces tumor volume and resolution exudative retinal detachment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Avastin have been met. Therefore, we decided that the Plan has to pre-approve
Avastin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045).

You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says the billed code has a column I / column II relationship with another code 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, we have confirmed that code 71045 has a column I / column II relationship with code 36556 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay the unlisted neurological or neuromuscular diagnostic procedure (95999) provided May 28, 2020.

You asked the Plan to pay the unlisted diagnostic procedure. You say that please review enclosed documentation and remit payment accordingly. The Plan denied your request. The Plan says this item or service is considered a bundled procedure as the cost is included in the cost of the primary procedure. Medicare does not make separate payment for this service.

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 the unlisted diagnostic procedure has a bundled relationship with the primary procedure and cannot be paid as billed. This code cannot be paid as a separate line item.

Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay the unlisted neurological or neuromuscular diagnostic procedure (95999) provided May 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient hospital services.

You asked the Plan to pay for inpatient care. You say that the enrollee requires inpatient care based on history, complex surgical approach, comorbidities, and current medical needs. The Plan denied your request. The Plan says the procedure is not on the inpatient only list, and the enrollee does not have poorly controlled co-morbid conditions.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 inpatient care. Our physician reviewer found that the enrollee is noted to have no significant uncontrolled chronic conditions that pre-operatively would warrant an in-patient level of care. The record does not show that the enrollee's necessary hospital care will span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient hospital services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (J9299).

You asked the Plan to pre-approve Opdivo. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the request for Opdivo does not meet medical necessity criteria.

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 Opdivo. Our reviewer says that the requested drug is not medically necessary and reasonable. Our physician reviewer found because the patient has failed Keytruda, another drug in same class of PDI inhibitors, the request for Opdivo cannot be approved. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo (J9299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services by an out of network (OON) provider.

You asked the Plan to pay for podiatry services. You say that the enrollee informed you that they were covered by Original Medicare, so authorization was impossible to obtain. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 medical services by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external insulin infusion pump for the enrollee.

You asked the Plan to pre-approve an external insulin infusion pump. You say that this should be covered by the Plan. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.

The Plan follows Medicare rules. Medicare rules say that an external insulin infusion pump is covered if the above criteria is 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 pre-approve an external insulin infusion pump. Our reviewer says that an external insulin infusion pump is not medically reasonable and necessary for the enrollee. The enrollee's C-Peptide level on January 14, 20201 was 4.47 (ref. range 0.80 - 3.85) with fasting glucose level of 210. Member also has stage 4 chronic kidney disease. 

As outlined in the Local Coverage determination, the following criteria have not been met: 
1. C-peptide level is less than or equal to 110 percent of the lower limit of normal of the laboratory's measurement method. 
2. For beneficiaries with renal insufficiency and a creatinine clearance (actual or calculated from age, weight, and serum creatinine) less than or equal to 50 ml/minute, a fasting C-peptide level is less than or equal to 200 percent of the lower limit of normal of the laboratory's measurement method. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for an external insulin infusion pump. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an external insulin infusion pump have not been met. Therefore, we decided that the Plan does not have to pre-approve an external insulin infusion pump for the enrollee.