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

We decided that the Plan does not have to pay for the drug services rendered on August 20, 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 J3490-59, J3411, J3415, J3490, and J1955-59 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 J3490 is unclassified drugs. The definition of code J3411 is injection, thiamine hcl, 100 mg. The definition of code J3415 is injection, pyridoxine hcl, 100 mg. The definition of code J1955 is injection, levocarnitine, per 1 gm. 

We find that CPT codes J3490, K3411, J3415, and J1955 are not supported in the medical record. Specifically, the documentation indicates that nutria-pharmaceutical blend was used and each component blend cannot be billed separately. 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 drug services rendered on August 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.

You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says the guidelines require an issue to be addressed in order for this study to be performed.

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 study. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not indicate the reason for the sleep study. You are having no issues with use of CPAP. The residual AHI is somewhat elevated at 9.2, but there is no indication that you are having related symptoms, such as excessive daytime sleepiness. A sleep study is not necessary for you to continue CPAP. You have reportedly withdrawn the request after peer-to-peer.

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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT of the head or brain (70450).

You asked the Plan to pay for the CT. You say that you would like reconsideration because the documentation submitted supports the level of service. The Plan denied your request. The Plan says code 70450 is a column II to column I code 70496.

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 CT has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Additionally, this claim was not submitted with a modifier to indicate that these services were separate and distinct. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for CT of the head or brain (70450).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and amalgam provided on September 11, 2020.

You asked the Plan to pay for the first intraoral periapical x-ray and amalgam. You say that these services should be covered because they were provided due to a medical condition. The Plan denied your request. The Plan says these services are not covered benefits.

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. These services are dental in nature, and the only x-rays that are covered under your plan are bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and amalgam provided on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a below-knee alignable system, flex-walk system, and multi-axial rotational unit for K3 level.

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 covered.

The Plan must follow Medicare rules. Medicare rules say that accessories for a K3 ambulator prosthesis are covered when specific criteria are met. 

We looked at the file and Medicare rules. The file shows that you are expected to continue to require the use of a cane and crutches with the prosthesis; therefore, the K3 ambulator status is not supported. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a below-knee alignable system, flex-walk system, and multi-axial rotational unit for K3 level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) provided September 9, 2020.

You asked the Plan to pay for the orthosis. You say that you are attaching documentation which supports the fact that the enrollee was treated by the physician. The Plan denied your request. The Plan says the records do not support the billed service.

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 physician order or relevant medical records which support medical necessity for the supplies provided in this case. The DME provider did not present medical records showing that the prescribing physician ever saw 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 knee orthosis (L1833) and suspension sleeve (L2397) provided September 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ninlaro 4 MG Capsule.

You asked the Plan to pre-approve Ninlaro 4 MG Capsule. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is a self-administered drug.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ninlaro 4 MG Capsule.

Benefits for Ninlaro 4 MG Capsule may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider.

You asked the Plan to waive the coinsurance for an injection. You say that you were told that this would be covered. The Plan denied your request. The Plan says the correct coinsurance has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $2,067.60. The total amount you are being asked to pay is $413.52 ($2,067.60 x 20% = $413.52). An injection 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 an injection provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the allowance for the hearing aids provided by an out of network provider.

You asked the Plan to pay the allowance for the hearing aids. You say that the Plan told you that you had $500 coverage on each ear. The Plan denied your request. The Plan says the claim was denied because the service was rendered by an out-of-network provider.

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 the allowance 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 at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay the allowance for these items. Therefore, we decided that the Plan does not have to pay the allowance for the hearing aids provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve straight footplate cover, calf panel, and roho adaptor pad for footplate (K0108).

You asked the Plan to pre-approve straight footplate cover, calf panel, and roho adaptor pad for footplate. You say that the items are medically necessary. The Plan denied your request. The Plan says the items do not have a medical purpose.

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 straight footplate cover, calf panel, and roho adaptor pad for footplate (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328).

You asked the Plan to pay for home infusion therapy. You say that this code has been paid on other claims. The Plan denied your request. The Plan says this 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.

We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95885, 95938, G0453, 95955).

You asked the Plan to pay for neuromonitoring services. You say that the time limit for filing should be extended due to the pandemic. The Plan denied your request. The Plan says claims must be filed within a year of the date of service.

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 neuromonitoring services was not filed. 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 neuromonitoring services (95885, 95938, G0453, 95955).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you need these because you are having foot pain and trouble walking. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says frequent injections are not needed each day that are adjusted based on blood glucose testing results.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are noted to have type II diabetes, for which she takes oral medications and a once-daily, fixed-dose of mixed insulin. How often you check your blood glucose levels is not documented. There is no evidence that you use the results of blood glucose testing to self adjust insulin dosages multiple times per day. As such, the use of a CGM 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is
important to know which providers are part of our network because, with limited exceptions, while you are a
member of our Plan you must use network providers to get your medical care and services. The only exceptions
are emergencies, urgently needed services when the Plan's network is not available (generally, when you are
out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network
providers.

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 did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the MR angiography of the head (70546).

You asked the Plan to pay for the MR angiography. You say that you would like reconsideration because this service was denied as a duplicate in error. The Plan denied your request. The Plan says that Current Procedural Terminology (CPT) code 70546 is a column II code to another code that was billed on the same date of service.

The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same beneficiary, same NPI nad same date of service to NCCI edits.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MR angiography have been met. Specifically, the record indicates that the column I and column II codes were rendered by different providers. It is only appropriate to apply the NCCI edits to claim lines with the same NPI. Therefore, we decided that the Plan has to pay for the MR angiography of the head (70546).

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: Lab
Decision: Favorable

We decided that the Plan has to pre-approve FoundationOne CDx testing provided to the enrollee.

You asked the Plan to pre-approve the services. You say that this test has FDA approval. The Plan denied your request. The Plan says that this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that services are covered when they are 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 the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the F1CDx is a next generation sequencing-based in vitro diagnostic test that is U.S. F1CDx is FDA-approved as a companion diagnostic for patients with non-small cell lung cancer, melanoma, colorectal cancer, ovarian cancer or breast cancer to identify patients who may benefit from treatment with one of 21 targeted therapies in accordance with FDA-approved therapeutic product labeling. Additionally, F1CDx is indicated to provide tumor mutation profiling to be used by qualified health care professional in accordance with professional guidelines in oncology. The review has determined that the enrollee meets the criteria for this testing.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve FoundationOne CDx testing provided to the enrollee.

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 the back brace.

You asked the Plan to pay for the services provided. You say that a physical exam is not required during the pandemic. The Plan denied your request. The Plan says there are no records showing the prescribing physician ever saw the enrollee.

The Plan must follow Medicare rules. Medicare rules say that the enrollee's medical record must contain sufficient documentation of their medical condition to substantiate the necessity.

We find that the back brace is not supported in the medical record. The records do not include previous medical records that show the enrollee's clinical course, or the extent of functional limitations. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the back brace.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit service.

You asked the Plan to pay for the home visit service. You say that the claim was filed timely but it did not process correctly because of a system glitch. The Plan denied your request. The Plan says the claim was 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 home visit service was not filed. 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 home visit service.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a portable oxygen concentrator (E1392) received from an out of network supplier.

You asked the Plan to waive the coinsurance for a portable oxygen concentrator. You say that a portable oxygen concentrator is required for overnight travel. The Plan denied your request. The Plan says the correct coinsurance was applied.

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 50% coinsurance for durable medical equipment when received from an out of network supplier.

You have been asked to pay $1,445, or 50% of the Medicare-allowed amount of $2,890, for a portable oxygen concentrator. A portable oxygen concentrator falls within the "Durable medical equipment (DME) and related 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 coinsurance for a portable oxygen concentrator (E1392) received from an out of network supplier.