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

We decided that the Plan does not have to pre-approve Synvisc-One. 
 
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 step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has left knee osteoarthritis. 
She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that 
the required drugs would be contraindicated or less effective; therefore, Synvisc-One is not reasonable or 
medically necessary at this time. 
 
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 Synvisc-One.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 31, 2019, by an
out-of-network (OON) provider.
You asked the Plan to pay for x-ray exam. You say that this provider was in-network. The Plan denied your
request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network
with the Plan.
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 provided on December 31,
2019, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 21, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing with records to justify this visit. The 
Plan denied your request. The Plan says the denial of payment for this service 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 provided on October 21, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulatory surgical injection procedure.

You asked the Plan to waive the copayment for outpatient surgery. You say that you should not have this cost-share for an in-network provider. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. The Plan also says that they have waived the coinsurance for the Iodine-125 imaging contrast materials, so you are only responsible for the $250 outpatient surgery copayment.

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 $250 copayment for ambulatory surgical center service.

You have been asked to pay $250 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 ambulatory surgical injection procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of the continuous positive airway pressure (CPAP) device (E0601).

You asked the Plan to pre-approve continued coverage of the CPAP device. You say that this service is medically necessary for your condition. The Plan denied your request. The Plan says the continued coverage of the CPAP device does not meet Medicare criteria for compliance.

The Plan follows Medicare rules. Medicare rules say that for continued coverage of CPAP devices, the enrollee must meet certain Medicare criteria.

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 continued coverage of the CPAP device. Our reviewer says that the continued coverage of the CPAP device does not meet relevant Medicare criteria. Our physician reviewer found in this case, there is documentation of non-adherence with the CPAP machine. The medical records demonstrate use at 20% (and averaged less than 4 hours on 100% of the dates used. Additionally, there is insufficient documentation of a recent face to face clinical re-evaluation. The review has determined that the enrollee does not meet criteria as listed in the LCD for continued coverage of the CPAP machine.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued coverage of the CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of the continuous positive airway pressure (CPAP) device (E0601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic CGM. You say that this device is medically necessary for 
your condition. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of 
the CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of the therapeutic CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494, 64495). 
 
You asked the Plan to pre-approve facet joint injections. You say that this is medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for facet joint injections to be covered, the 
patient must have history of at least 3 months of moderate to severe pain with functional impairment and pain 
is inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy (as 
tolerated).   
 
We looked at the file and Medicare rules. The submitted medical records do not document that the enrollee's 
pain is inadequately responsive to physical therapy. Based on this information, we decided that Medicare rules 
for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to 
pre-approve facet joint injections (64493, 64494, 64495).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection of regadenoson provided on 
September 21, 2020. 
 
You asked the Plan to waive the coinsurance for injection. You say that you would expect that this injection 
would be included within the $325 copayment for your stress test. The Plan denied your request. The Plan says 
the coinsurance amount you are being charged is correct. 
 
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 in-network regadenoson injection. The allowed amount of the claim is $236.72, resulting in a 
coinsurance obligation of $47.34. 
 
You have been asked to pay 20% coinsurance for injection. 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 of 
regadenoson provided on September 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a second chest x-ray review provided on September 11, 
2020. 
 
You asked the Plan to pay for a second chest x-ray review. You say that the records support the procedure. The 
Plan denied your request. The Plan says the records support one procedure which was already paid for. 
 
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 71045-26 is Radiologic examination, chest; single view, 
professional component. 
 
We find that CPT code 71045-26 is not supported in the medical record. Specifically, the submitted record 
supports one service. Based on this information, we decided that Medicare rules for coverage of the chest x-ray 
review have not been met. Therefore, we decided that the Plan does not have to pay for a second chest x-ray 
review provided on September 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 4, 
2020, and billed under code 71046, Q0092 and R0070. 
 
You asked the Plan to pay for imaging services provided to the enrollee. You say that this claim should be paid. 
The Plan denied your request. The Plan says Medicare billing criteria are not met. The Plan states for services 
provided in a facility, specific place of service codes is used. The Plan says for services that are provided in a 
facility place of service and that are subject to the professional or technical component or that have both a 
Professional Component and a Technical Component according to the Medicare guideline indicators, the Plan 
will only pay the Professional Component as the facility is reimbursed for the Technical Component of the 
service. For services provided that have both components, a "CMS PC/TC Indicator 1" and must be reported 
with modifier 26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate place of service codes and when required the appropriate 
modifiers. In this case the claim cannot be paid due to an issue with the place of service code used. Medicare 
billing criteria are not met. Therefore, we decided that the Plan does not have to pay for imaging services 
provided to the enrollee on November 4, 2020, and billed under code 71046, Q0092 and R0070.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a continuation of a care with an out of network (OON) provider 
 
You asked the Plan to pre-approve the continuation of care with an OON provider. You say that the enrollee 
has been under your care for several years. You say that the enrollee wants to remain under your care and 
continue her dialysis treatments where she has been getting them in order to maintain a continuity of care. The 
Plan denied your request. The Plan says that they have in-network providers who can manage the enrollee's 
care. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 [[CASE/DECISION_TREE/PAYPROVIDE] the 
continuation of care with an OON provider. Our reviewer says that the criteria for coverage of out of network 
care have been met. Our physician reviewer found End Stage Renal Disease patients have an annual mortality 
of 20%.  This is exceedingly high, and disruptions of care and transitions of care carry significant risks.  A 
hemodialysis patient is at very high risk for complications and for proper management intimate knowledge of 
the specific patient is vital. Disruption of care has the potential to cause significant morbidity to the enrollee. 
Our physician reviewer found that continuity of care in this instance is important and that the request for OON 
care is medically 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 continuation of care with an OON provider have been met. Therefore, we 
decided that the Plan has to pre-approve a continuation of a care with an out of network (OON) provider  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chiropractic office visit (99202) and an x-ray (72100) 
provided on September 16, 2020. 
 
You asked the Plan to pre-approve a chiropractic office visit and an x-ray. You say that this should be covered 
because it would be covered in other circumstances. The Plan denied your request. The Plan says these services 
are not covered when provided by a chiropractor. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pre-approve a chiropractic office visit (99202) and an x-ray (72100) provided on 
September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on February 25, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for an OON office visit. You say that this was a medically necessary service 
provided in good faith. The Plan denied your request. The Plan says this was 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 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 office visit (99214) provided on February 25, 
2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for budesonide. 
 
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 drug is not eligible for a tier exception. 
 
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are for Part D covered drugs only. 
 
We looked at the file and Medicare rules. The requested tier exception is for a Part B covered drug. This drug is 
not eligible for a tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier 
exception for budesonide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, first 15 minutes of deep sedation/general anesthesia, and each subsequent 15 minute increment of deep sedation/general anesthesia.

You asked the Plan to pay for the extraction and deep sedation/general anesthesia services. You say that you were referred to go to this provider. The Plan denied your request. The Plan says you must pay 100% for Class 3 Major Services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the cost for Class 3 Major Services. Therefore, we decided that the Plan does not have to pay for the extraction, first 15 minutes of deep sedation/general anesthesia, and each subsequent 15 minute increment of deep sedation/general anesthesia.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit. 
 
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 the enrollee has myelodysplastic 
syndrome with 10 percent blasts and is JAK-2 positive. The documentation does not support that he has low-
intermediate risk myelodysplastic syndrome. The records do not support that the Retacrit is safe and effective 
and reasonable and medically necessary for the 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Retacrit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 8, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for nebulizer with supplies. You say that you supplied these items with the 
understanding that you would be paid. The Plan denied your request. The Plan says the denial of payment for 
these items 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 provided on September 8, 
2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for blended drugs provided to the enrollee on May 14, 2020 and 
billed under codes J3411, J3415, and J3490. 
 
You asked the Plan to pay for this claim as billed. You say that this claim should be paid. The Plan denied your 
request. The Plan says because a nutria-pharmaceutical blend was administered; each component of the blend 
cannot be billed separately. The Plan states that the appropriate unit for the nutri-pharmaceutical blend has 
already been processed on the billed date of service; therefore, the billed code cannot be verified. The Plan 
states multiple attempts were made to contact the provider to obtain additional information regarding the 
medication and dosage administered, however no response was received.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed 
because the drug components are not allowed to be billed separately. Medicare rules for coverage of this claim 
as billed have not been met. Therefore, we decided that the Plan does not have to pay for blended drugs 
provided to the enrollee on May 14, 2020 and billed under codes J3411, J3415, and J3490.