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

We decided that the Plan does not have to pay for the eye exam (92014), refraction (92015) and diagnostic imaging (92133) provided by an out of network (OON) provider.

You asked the Plan to pay for the ophthalmological services. You say that this provider is in-network for the 2021 Plan year, so you assumed they were also in-network for 2020. The Plan denied your request. The Plan says they only cover out-of-network care in limited circumstances. The provider in question was not in the Plan's network at the time of service. The care provided was not urgent or pre-approved and could have been provided in-network.

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 eye exam (92014), refraction (92015) and diagnostic imaging (92133) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician attendance and supervision of hyperbaric oxygen
therapy, per session (99183) provided from June 19, 2020, to June 24, 2020.
You asked the Plan to pay for hyperbaric oxygen therapy. You say that the same notes you sent to obtain the
authorization is the same with additional once sent to facilitate the payment of the claim The Plan denied you request. The Plan says the records do not support the services 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, the CPT Code Manual definition of code 99183 is physician attendance and supervision of hyperbaric oxygen therapy, per session. We find that CPT code 99183 is not supported in the medical record. Specifically, the records provided did not
include documentation of physician or qualified health care professional attendance and supervision of
hyperbaric oxygen therapy, per session. The records show that multiple attempts were made to obtain the
additional information from the provider. Based on this information, we decided that Medicare rules for
coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the Plan does not have to
pay for physician attendance and supervision of hyperbaric oxygen therapy, per session (99183) provided from June 19, 2020, to June 24, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care.

You asked the Plan to waive the copayment for emergency care. You say that you had COVID-19 symptoms
and cannot afford 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 $90
copayment for emergency care.

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency
care 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 emergency care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 additional home health visits for PT.

You asked the Plan to pre-approve additional PT visits. You say that you are not completely healed and that your ankle does not want to cooperate after walking a distance. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 additional PT visits. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found that the requested additional PT is not generally accepted as specific and effective therapy for your condition beyond what was approved by the Plan. You have had prior therapy of at least 26 home care PT visits and the records do not demonstrate that the unique skills of a professional physical therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a physical therapist, or for PT, by or under the supervision of a physical therapist given your current functional level. You have been instructed, and are compliant, in a home exercise program. You have been educated on fall prevention, environmental modifications and home safety. The requested services are not part of a maintenance program, nor are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 additional home health visits for PT.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guaradnt360 testing.

You asked the Plan to pay for the Guaradnt360 testing. You say that you would like reconsideration because
this is the only provider that renders Guaradnt360 testing. The Plan denied your request. The Plan says
service providers should use CPT code 81479.

The Plan must follow Medicare rules. Medicare rules say that one unit of CPT code 81479 is used to report
Guardant360 testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Guaradnt360 testing have not been met. Specifically, one unit of CPT code 81479 must be
used to report this testing. Therefore, we decided that the Plan does not have to pay for Guaradnt360 testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing.

You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because
this is the only service provider for this testing. The Plan denied your request. The Plan says Medicare requires
use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling for lung cancer.

The Plan must follow Medicare rules. Medicare rules say that one unit of CPT code 81479 is used to report
Guardant360 testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Guardant360 testing have not been met. Specifically, this testing was not billed correctly. It is
not appropriate to unbundle the services for this testing. Guardant360 testing must be billed with CPT code
81479. Therefore, we decided that the Plan does not have to pay for Guardant360 testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses (L1833) and suspension sleeves (L2397).

You asked the Plan to pay for the knee orthoses and suspension sleeves. You say that the requested items were
medically necessary. The Plan denied your request. The Plan says there was no relationship between the
ordering physician and the enrollee.

The Plan follows Medicare rules. Medicare rules say that a knee orthosis and suspension sleeve is subject to the
criteria listed in the Medicare rules section.

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 knee orthoses and suspension sleeves.
Our reviewer says that the requested items were not medically necessary and reasonable. Our physician
reviewer found There is no documentation of recent injury to, or recent surgical procedure on, either of the
enrollee's knees, and there is insufficient credible objective documentation of joint laxity. In addition, when the
knee orthosis is not eligible for coverage the related suspension sleeve will also not be covered.

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 knee orthoses and suspension sleeves have not been met. Therefore, we
decided that the Plan does not have to pay for the knee orthoses (L1833) and suspension sleeves (L2397).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested device. You say that the enrollee's illness has brought on additional chronic illnesses. The Plan denied your request. The Plan says coverage criteria have not been met.

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 does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires 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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasound of the stomach for the enrollee.
You asked the Plan to pre-approve the ultrasound. You say that this is needed due to lower quadrant abdominal
discomfort. The Plan denied your request. The Plan says no history, physical, or prior imaging results were
submitted to establish medical necessity.
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 ultrasound. Our reviewer says that
the requested ultrasound is not considered medically reasonable and necessary in this case. Our physician
reviewer found whereas ultrasound of the abdomen and/or pelvis may have value in elucidating the cause of
abdominal pain for many patients, the records provide no history, physical, nor prior imaging or lab results to
establish medical necessity for the service in dispute.
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 ultrasound have not been met. Therefore, we decided that the Plan does not
have to pre-approve an ultrasound of the stomach for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an endoscopy provided by an out-of-network (OON) provider.

You asked the Plan to pay for an endoscopy. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that these services were not emergent.

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 an endoscopy provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee.

You asked the Plan to pay for this service. You say that inpatient mental health care was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 this service. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the Plan's denial of inpatient psychiatric services is correct. The medical records show the enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. It did appear that the records were supervised and evaluated by a physician. Based on the records provided, Medicare criteria for inpatient admission were not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee.
Appeal type: Drugs
Decision: Favorable

The rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Grievance Manual, Section 50.12.1.
The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only
Manual, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1.
Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a
medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to
other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines
that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must
show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or
adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or
other harm to the enrollee.
Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B
drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B
drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Section 423.578(b)(5)(ii) If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coflex Interspinous device services.

You asked the Plan to pay for the Coflex Interspinous device services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are 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 pay for the Coflex Interspinous device services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Coflex device remains experimental is spinal surgery. More research is needed to show safety and efficacy. There is no documented spinal instability. Therefore, the enrollee did not meet criteria for the services rendered.

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 Coflex Interspinous device services have not been met. Therefore, we decided that the Plan does not have to pay for the Coflex Interspinous device services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3348) for tooth #30.

You asked the Plan to pre-approve the dental services. You say that this is medically necessary, as the enrollee is in pain. The Plan denied your request. The Plan says the services are not listed as a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3348) for tooth #30.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia.

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 that 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 medically necessary. Our physician reviewer found the enrollee has a past medical history of bilateral hip replacements and osteoporosis, as documented by bone density testing and Alendronate intolerance. Prolia is approved by the Food and Drug Administration for the treatment of postmenopausal osteoporosis with high risk of fracture. This patient meets these criteria with T-scores of -2.9 and -2.6 on bone density testing of the distal radius and she is high risk for fracture by the Fracture Risk Assessment Tool (FRAX). Although no hip bone density score is possible in this enrollee, the FRAX score can be calculated based on clinical risk factors alone. Based on clinical risk factors alone, she is at high risk for osteoporotic fracture. The Prolia is safe and effective and reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve Prolia.

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 pre-approve oral nutritional supplements for the enrollee.

You asked the Plan to pre-approve oral nutritional supplements. You say that this product is medically necessary for the enrollee. The Plan denied your request. The Plan says nutritional supplements are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve oral nutritional supplements for the enrollee.
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 Synvisc-One. You say that you have tried alternatives. The Plan denied your request. The Plan says step therapy requirements have not been 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 Synvisc-One. Our reviewer says that the criteria for coverage of Synvisc-One have not been met. Our physician reviewer found the Plan requires a trial of Euflexxa, Durolane, Supartz-FX, or Gelsyn-3 before they will approve the requested drug, Synvisc-One. The medical records do not show that you have tried any of the requested drugs, or that these drugs would likely be less effective or have adverse effects. 

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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.