Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care, per day (99309) provided April 2, 2021.

You asked the Plan to pay for the subsequent nursing facility care. You say that please reprocess and pay accordingly as your provider rendered services to this enrollee on this date of service. The Plan denied your request. The Plan says this provider is not Medicare certified and the SA modifier is non-covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Also, modifier SA is used to indicate a nurse practitioner rendering service in collaboration with a physician. Medicare does not accept modifier SA. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care, per day (99309) provided April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided from March 15, 2021, to March 24, 2021.

You asked the Plan to pay for the office visit (99202), radiological exam (72110), or electrical stimulation (G0283). You say that your visits should be covered as physical therapy at $12 a visit. The Plan denied your request. The Plan says these services when provided by a chiropractor are never covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided from March 15, 2021, to March 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 for the enrollee.
You asked the Plan to pre-approve Gelsyn-3. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there is no indication their preferred agent(s) would likely be less effective, and/or cause adverse effects for the member.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Gelsyn-3. Our reviewer says that Gelsyn-3 is not medically reasonable and necessary for the enrollee. The enrollee has not tried and failed Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Gelsyn-3. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99072, S1015, S8301) provided on March 1, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not payable.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. Medicare rules also say that
We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for code 99072. Codes S1018 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 the services (99072, S1015, S8301) provided on March 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (13122) provided on January 15, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled code.
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 13122 has a bundled relationship with code 27248 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 the services (13122) provided on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 28, 2021.
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to obtain authorization before receiving services. The contract with the Plan says that for some types of services, the enrollee's PCP may need to get approval in advance from our plan.
The requested provider in this case is not a network provider with the Plan. Physician specialist services required prior authorization. The Plan did not pre-approve the services at issue. 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 the office visit provided by an out-of-network provider on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on January 13, 2021.

You asked the Plan to waive the deductible for an office visit. You say that you were not aware that you were a day early to switch providers. 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 $198 deductible which applies to physician/practitioner services, including doctor's office visits. 

You had an office visit on January 13, 2021. The record shows that you had paid $0 toward the $198 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $66.79. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible which applies to physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on January 13, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair 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 follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation is conflicting on the need for the requested device and accessories. The physician physical exam notes non-focal neurological exam, normal upper and lower extremity strength, and sensory exam intact. This is not consistent with the occupational therapy wheelchair evaluation that indicates a group 3 wheelchair is needed due to progressive weakness. Additionally, there are no details about the current wheelchair, and why it is unable to be repaired rather than replaced. The physician progress note with normal strength in the upper extremities does not support that this patient requires codes E2311, E2377, E2313 with 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 enrollee 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 (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength in the upper extremities supports that the patient can control any power options through their own individual switches. Furthermore, the documentation notes the patient requires a Group 3 wheelchair due to progressive weakness however this is not consistent with the medical progress notes from the physician and there is no Group 3 qualifying diagnosis. The documentation does not support the need for the requested power mobility device. 

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 power wheelchair and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325) for bilateral osteoarthritis knee.
You asked the Plan to pre-approve Synvisc-One; Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg (J7325).

You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says there is insufficient documentation by imaging of joint space narrowing, subchondral sclerosis, osteophytes,or sub-chonral cysts.

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 Synvisc-One ; Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg (J7325). Our reviewer says that the requested drug is not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding detailed radiologic evidence of osteoarthritis such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. The x-ray films provided were reportedly of poor copy quality and unaccompanied by an official radiologist's report. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Synvisc-One, Hyaluronan or derivative, Synvisc or Synvisc-one for intra-articular injection, 1 mg (J7325) is not medically reasonable or necessary and does not meet the guidelines. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One; Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg (J7325) have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325) for bilateral osteoarthritis knee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.

You asked the Plan to pre-approve a SI joint injection. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 a SI joint injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria requires 3 physical exam tests be used to document Sacroiliitis which are not present. A SI joint injection should not be scheduled on the same day as other pain interventional procedures. The request is considered 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 a SI joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor 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 there is no insulin treatment regimen that requires frequent adjustment by the enrollee on the basis of blood glucose monitor or 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 the case file states that the enrollee has type 2 diabetes and uses once daily long acting insulin according to plan claim data. No medical records were submitted for review. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for a continuous glucose monitor (CGM).
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 nto covered.
The Plan must follow Medicare rules. Medicare rules say that a sensor described by code A9276 is for use with a non-therapeutic CGM. We looked at the file and Medicare rules. The services at issue are a sensor described by code A9276. This sensor is for a non-therapeutic CGM, which is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve sensors for a continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have no documented daily skilled nursing needs and at the current level of function, you do not require daily skilled therapies in an inpatient setting. 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alimta (Pemetrexed) and Tecentriq (Atezolizumab).
You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says the drugs are not being requested for a medically-accepted indication.
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 the requested drugs. Our physician reviewer found that the enrollee has a diagnosis of predominantly lepidic pattern adenocarcinoma of the lung with metastases to lymph nodes. PDL-1 is positive greater than 50%. Initial chemoradiation therapy has been completed. The requested regimen is not FDA-approved for the enrollee's diagnosis. The drug regimen at issue in this case is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.
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 requested drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Alimta (Pemetrexed) and Tecentriq (Atezolizumab).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided by an out-of-network provider on April 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve full mouth debridement to enable a comprehensive oral
evaluation and diagnosis on a subsequent visit (D4355).
You asked the Plan to pre-approve full mouth debridement to enable a comprehensive exam. You say that he
enrollee needs the service covered. The Plan denied your request. The Plan says the enrollee recently received
an oral exam and is not yet eligible for the debridement service.
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. The Plan covers full mouth
debridement to enable a comprehensive exam every 3 years when it is not performed on the same day or less
than 1 calendar year after an evaluation.
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral
evaluation (D0150) was covered on July 13, 2021. Based on this information, we decided that the Plan's rules
for coverage of full mouth debridement to enable a comprehensive exam have not been met. Therefore, we
decided that the Plan does not have to pre-approve full mouth debridement to enable a comprehensive oral
evaluation and diagnosis on a subsequent visit (D4355).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit (99213) provided on December 23,
2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly
to the service provided.

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. Specifically, an Evidence of Coverage (EOC) booklet that indicates medical
coverage and applicable copayments for services provided was not included in the case file. Therefore, we
decided that the Plan has to waive the copayment for the office visit (99213) provided on December 23, 2020.

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.