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

We decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on March 5, 2021.

You asked the Plan to pay for the eye exam. You say that the patient couldn't choose an in-network optometrist since no other provider was allowed in the facility during the pandemic. You say that it is not possible to request authorization before services are rendered and the claim should be reprocessed for reimbursement. The Plan denied your request. The Plan says the provider is not a participating provider with the Plan and authorization was not obtained prior to the services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 provided by an out-of-network provider on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames and lenses received on February 3, 2021.

You asked the Plan to pay for deluxe frames and lenses. You say that the items should be covered, and you want the Plan to pay. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when a Plan provider is utilized. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of deluxe frames and lenses have not been met. Specifically, services were provided by an out-of-network provider. The Plan has contracted providers available to provide these services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for deluxe frames and lenses received on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient specimen collection rendered on January 5, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory tests not payable on the Clinical Diagnostic Laboratory Fee Schedule (CLFS) will be based on OPPS. 

We looked at the file and Medicare rules. The file shows that the claim was billed under OPPS and these services are not payable under this payment system. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient specimen collection rendered on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on January 19, 2021 by an out of network (OON) provider.

You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and paid due to medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 outpatient services provided on January 19, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits with an orthopedic specialist to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve office visits with a specialist. You say that you would like to be referred out of plan because you want to be provided effective trigger point injections within 1 to 5 days of flare up. The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan also says that you are required to obtain this service from in-network providers.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits with an orthopedic specialist to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses lenses (V2300, V2781) purchased on February 8, 2021.

You asked the Plan to pay for the eyeglass lenses. You say that you did not realize that you could only purchase new glasses within a specific timeframe. You would like the Plan to provide an exception in your case and grant you the $100 allowance, as your benefits would have been available if you had waited one day to make the purchase. The Plan denied your request. The Plan says you previously purchased eyewear through your routine vision benefit on February 9, 2019. Your benefit only provides the $100 allowance every two years. This benefit is administered on a rolling calendar year since your last date of service, so your benefits did not reset until February 9, 2021.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to $100 every two years. This benefit is based on a rolling calendar year from your last date of service. 

We looked at the file and the Plan's rules. Your previous purchase was made on February 9, 2019. Exactly two rolling calendar years had not elapsed between service dates. Based on this information, we decided that the Plan's rules for coverage of the eyeglass lenses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses lenses (V2300, V2781) purchased on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the lab services provided on February 2, 2021.

You asked the Plan to waive the copay for the lab services. You say that you never had tests done during the appointment. The Plan denied your request. The Plan says you remain liable for the testing.

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 $10 copay for Medicare-covered lab tests. 

The medical records show that you received drug testing services. You have been asked to pay a $10 copay for the lab services. The services fall within the outpatient diagnostics tests 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 copay for the lab services provided on February 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization.

You asked the Plan to pre-approve inpatient psychiatric hospitalization. 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 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 pre-approve inpatient psychiatric hospitalization. Our reviewer says that the service is not medically necessary. Our physician reviewer found it is not expected you would improve in a reasonable period of time beyond the dates in question as you are not showing signs of any danger to self or others, auditory or visual hallucinations, you are without aggressive behaviors and do not show any acute threats of safety. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospitalization have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means this service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with a pulmonary specialist (99205, 99245) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an office visit with a specialist. You say that you have lost confidence in the in-network medical care. The Plan denied your request. The Plan says there are in-network providers available for these services.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The records provided for review do not show that the services at issue are urgent or emergent. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit with a pulmonary specialist (99205, 99245) to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EKG provided by a participating provider on November 30, 2020.

You asked the Plan to waive the copayment for an EKG. You say that you have to get an EKG every 3 months. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for outpatient diagnostic tests/specialist. 

You have been asked to pay a $15 copayment for an EKG. The correct copayment has been applied to the EKG that was provided. An EKG falls within the outpatient diagnostic tests/specialist 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 EKG provided by a participating provider on November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on July 1, 2020.

You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The genetic testing at issue in this appeal was requested solely for screening purposes. There were no medical records supporting that this genetic testing was ordered by the physician treating the enrollee. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an electronic knee, advanced foot, alignable system, extra socket insert features and other features (L5828, L5845, L5848, L5856, L5981).

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 documentation does not support that the enrollee requires K3 or above prosthetic limb items. The documentation notes significant comorbidities, malaise, chronic pain, fatigue, and dyspnea with exertion. You have been using a group 2 power wheelchair since 2017. The requested items are 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 prosthetic leg with an electronic knee, advanced foot, alignable system, extra socket insert features and other features (L5828, L5845, L5848, L5856, L5981).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.

You asked the Plan to pre-approve ten (10) additional PT visits. You say that the additional PT is medically necessary. The Plan denied your request. The Plan says the additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 ten (10) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had extensive prior therapy for her low back condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's 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 ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you need these services to help build strength.
The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an
intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care
services.

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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultraviolet therapy, intravenous infusion, for therapy, prophylaxis, or diagnosis, and infrared therapy provided from September 26, 2020, to December 1, 2020.

You asked the Plan to pay for the naturopathic services. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered benefits.

The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. 

The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for the ultraviolet therapy, intravenous infusion, for therapy, prophylaxis, or diagnosis, and infrared therapy provided from September 26, 2020, to December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for CT scans of the thorax (71250) and of the
abdomen and pelvis (74176) provided on March 30, 2020, and February 24, 2021.

You asked the Plan to waive the copayments for CT scans of the thorax and of the abdomen and pelvis. You
say that each time you went to the provider you were told you did not have to pay anything. The Plan denied
your request. The Plan says the correct copayments were applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for a Medicare-covered diagnostic CT scan at a freestanding provider.

You have been asked to pay a $50 copayment per date of service for CT scans of the thorax and of the abdomen and pelvis. CT scans of the thorax and of the abdomen and pelvis fall within the "Outpatient Diagnostic Tests and Therapeutic Services and 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 copayments for CT scans of the thorax (71250) and of the abdomen and pelvis (74176) provided on March 30, 2020, and February 24, 2021.

Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibility from the provider 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits provided from December 2, 2020, to March 23, 2021.

You asked the Plan to waive the copayments for office visits. You say that you were told that there would be 100% coverage for a mental health program. The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $10 copayment for each outpatient mental health visit. There were 16 visits, resulting in a total copayment amount of $160. 

You have been asked to pay $10 copayment for each office visit. Office visits fall within the Outpatient Mental Health 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 copayments for office visits provided from December 2, 2020, to March 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy (PT) evaluation (97163) therapeutic exercise (97110) provided March 25, 2021.

You asked the Plan to waive the copayment for the PT services. You say that you are in desperate need of physical therapy. The copayment required is beyond your financial capabilities as you are on SSDI. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage.

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 $40 copay per day for physical therapy services for Outpatient rehabilitation services.

You have been asked to pay $40 copay per day for physical therapy services for the PT services. the PT services falls within the Outpatient rehabilitation services 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 physical therapy (PT) evaluation (97163) therapeutic exercise (97110) provided March 25, 2021.