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

We decided that the Plan does not have to waive the coinsurance for the abatacept injection provided on June 17, 2021.

You asked the Plan to waive the coinsurance for the abatacept injection. You say that you had an infusion, not an injection of abatacept. The Plan denied your request. The Plan says you had an infusion, not an injection of abatacept.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B chemotherapy prescription drugs and non-chemotherapy prescription drugs.

You have been asked to pay $867.45, which is 20% of the allowed amount for the abatacept injection. The allowed amount is $4,337.25 (20% x $4,337.25 = $867.45). The abatacept 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 the abatacept injection provided on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313), power seat elevation feature (E2300) and flip-up platform (K0108).  You asked the Plan to pre-approve the accessories for a power wheelchair.. You say that these items are medically necessary. The Plan denied your request. The Plan says the criteria for coverage for these items have not been met.  

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The rules also say that a power seat elevation feature is statutorily noncovered. The rules also say that an expandable controller is subject to the criteria listed in the Medicare rules section.  

The flip-up platform 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. In addition, the power seat elevation feature is statutorily noncovered.  

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 for the expandable controller. Our reviewer says that the requested expandable controller is not medically reasonable and necessary. Our physician reviewer found that the documentation does not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices, or an attendant control. The patient's ability to be set up for eating supports the patient can control any power options through their own switches.  

Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313), power seat elevation feature (E2300) and flip-up platform (K0108).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing (F1 Heme) provided to the enrollee on May 27, 2021.  You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary and screening testing.  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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this genomic sequence analysis panel, CPT 81455 Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes, is non-covered by Medicare. Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and are denied automatically as not medically necessary and screening testing. The review has determined that the enrollee does not meet 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (F1 Heme) provided to the enrollee on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve Stimulation (TENS) device (E0731), provided on July 30, 2021.  

You asked the Plan to pay for the TENS device. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.  

The Plan must follow Medicare rules. Medicare rules say that the TENS device is covered when the all of the criteria in the Medicare Rules section of this letter are met. 

 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the TENS device have not been met. Therefore, we decided that the Plan does not have to pay for the Transcutaneous Electrical Nerve Stimulation (TENS) device (E0731), provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine office visits provided on March 3, 2021 to August 5, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the routine visits. You say that you would like reconsideration because you were not told that these providers were out-of-network. The Plan denied your request. The Plan says services must be rendered in-network to be covered.  

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 providers in this case are not network providers 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 routine office visits provided on March 3, 2021 to August 5, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a knee brace (L1833) and a neuromuscular stimulator (E0745) provided on March 17 to April 17, 2021.  

You asked the Plan to waive the coinsurance for a knee brace and a neuromuscular stimulator. You say that you forewarned your provider that you could not afford any therapy equipment if you had to pay for it. 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 20% coinsurance for Medicare-covered durable medical equipment items.     

You have been asked to pay $97.83, or 20% of the Medicare-allowed charge of $489.17, for a knee brace and $20.84, or 20% of the Medicare-allowed charge of $104.21, for a neuromuscular stimulator, a knee brace and a neuromuscular stimulator fall 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 knee brace (L1833) and a neuromuscular stimulator (E0745) provided on March 17 to April 17, 2021.   

Your complaint about paying for durable medical equipment items you say you did not request and that proved detrimental to your healing is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve replacement of a manual wheelchair.  

You asked the Plan to pre-approve replacement of a manual wheelchair. You say that this item is medically necessary. The Plan denied your request. The Plan says the criteria for coverage of a replacement wheelchair have not been met.  

The Plan must follow Medicare rules. Medicare rules say that during the reasonable useful lifetime of durable medical equipment, replacement is not covered in most circumstances.   

We looked at the file and Medicare rules. In this case, the file shows that you received a custom manual wheelchair in October 2020. Since this is less than 5 years ago and the file does not show it was damaged or you have had a change in condition, a replacement wheelchair will not be covered. Based on this information, we decided that Medicare rules for coverage of replacement of a manual wheelchair have not been met.         

Therefore, we decided that the Plan does not have to pre-approve replacement of a manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group three (3) power wheelchair with power tilt, power recline, and accessories for the enrollee.  

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested wheelchair with multiple power options exceeds the enrollee's medical needs. The documentation does not reveal that the enrollee is at high risk for development of a pressure ulcer, or utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. The documentation does not support that it is medically necessary to control three power options through the joystick (drive interface). While the enrollee has a congenital skeletal condition that would meet a qualifying diagnosis for a Group 3 wheelchair she does not require multiple power options therefore the requested base wheelchair with multiple power options is not medically necessary.   

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group three (3) power wheelchair with power tilt, power recline, and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for renal dialysis services provided on August 1, 2021.  You asked the Plan to waive the coinsurance for renal dialysis services. You say that you were told by a social worker that you should not be responsible for 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 $0 copayment for kidney disease education services and 20% coinsurance for renal dialysis services.  You received renal dialysis services on August 1, 2021. The total allowed amount is $371.87 and 20% of that is $74.37.   You have been asked to pay the total coinsurance amount of $74.37 for renal dialysis services. Renal dialysis services fall within the services to treat kidney disease 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 renal dialysis services provided on August 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the oxygen concentrator and supplies (E1390 and (91999) provided on March 25, 2021.  You asked the Plan to reimburse you for the oxygen supplies. You say that you would like reconsideration for the reimbursement of the oxygen equipment. The Plan denied your request. The Plan says the claim denied correctly according to your plan benefits & Medicare guidelines.  The Plan must follow Medicare rules. Medicare rules say that contractors may not pay for oxygen equipment that is purchased on or after June 1, 1989.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen supplies have not been met. Specifically, the record indicates that this oxygen equipment was purchased. Neither Medicare nor your Plan pay for oxygen equipment that is purchased. Therefore, we decided that the Plan does not have to reimburse you for the oxygen concentrator and supplies (E1390 and (91999) provided on March 25, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Introduction of needle or intracatheter (36000), the Hepatic function panel (80076), and the IV tubing extension set (S1015) provided on April 7, 2021.  You asked the Plan to pay for codes 36000, 80076, and S1015. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 36000 is a column II code to column I codes 96365 and 96375. We have also confirmed that code 80076 is a column II code to column I code 80053. This claim has not been billed with appropriate modifiers to bypass these edits.   Furthermore, CPT code S1015 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service.  Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Introduction of needle or intracatheter (36000), the Hepatic function panel (80076), and the IV tubing extension set (S1015) provided on April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) of the head and brain (70450) provided on September 12, 2021.

You asked the Plan to pay for the CT of the head and brain. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a Procedure to Procedure (PTP) edit exists between the appealed procedure code 70450 and 70496, billed on the same claim.

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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) of the head and brain (70450) provided on September 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Actemra pre-filled syringes.  

You asked the Plan to pre-approve self-administered drug. You say that the enrollee has used this drug for several years and his condition has been under excellent control. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  

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 Actemra pre-filled syringes.   

Benefits for self-administered drug 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 19, 2021. 

 You asked the Plan to pay for the prophylaxis. You say that your dentist wants you to come in every three months for a cleaning but because of the cost and your limited income, you usually stretch it out to every four months. The Plan denied your request. The Plan says this service exceeds the frequency limitation in 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, prophylaxis (D1110) is limited to two procedures per plan year. The record shows that you received prophylaxes (D1110) on January 14, 2021, and May 17, 2021 and your prophylaxis (D1110) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency anesthesia (99140) provided on April 19, 2021.

You asked the Plan to pay for emergency anesthesia. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.

We looked at the file and Medicare rules. Code 99140 has a status indicator of B and is not separately payable. Based on this information, we decided that Medicare rules for coverage of emergency anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for emergency anesthesia (99140) provided on April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued dental care with an out-of-network provider. 

 You asked the Plan to pre-approve out-of-network dental care. You say that you need additional dental work and would like to return to this provider. The Plan denied your request. The Plan says out-of-network dental care is not covered by your plan. There are several in-network providers who are able to perform the necessary 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. Preventative and comprehensive dental services are only covered when received from a provider who participates in the Plan's specified dental vendor network.  

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services provided out-of-network are not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve continued dental care with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the gauze (A6402) provided on April 22, 2021.  

You asked the Plan to pay for the gauze. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code A6402 has a status indicator of P indicating that payment for these supplies is always bundled.    

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 A6402 is gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing   

We find that CPT code A6402 is not supported in the record. Specifically, CPT code A6402 has a status indicator of P. This means that no separate payment is made for these supplies. Payment for the supplies is bundled into the payment for the physician services. Based on this information, we decided that Medicare rules for coverage of the gauze have not been met. Therefore, we decided that the Plan does not have to pay for the gauze (A6402) provided on April 22, 2021.