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

We decided that the Plan does not have to pre-approve a referral for deep brain stimulator surgery with an out-of-network provider.
You asked the Plan to pre-approve the referral. 

You say that this is medically necessary. The Plan denied your request. The Plan says the services can be 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 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. 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 a referral for deep brain stimulator surgery with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair battery.

You asked the Plan to pre-approve a power wheelchair battery. You say that you require the battery as soon as possible to be mobile. The Plan denied your request. The Plan says you do not qualify for the Power Wheelchair, so it will not pay for a battery replacement or repairs.

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. You have not been evaluated for a Power Wheelchair to determine if you require it. Since we cannot determine if you meet requirements for the power wheelchair, the power wheelchair battery is denied. 

The file shows that, this means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair battery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.

You asked the Plan to pre-approve additional inpatient psychiatric hospital services. You say that you need monitoring due to changes in your medicine. The Plan denied your request. The Plan says you do not meet criteria for this level of care.

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 hospital services. Our reviewer says that the service is not medically necessary. Our physician reviewer found based upon review of the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment. The patient could have been treated in a lesser restrictive setting as the patient was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to 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 hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided by an out of network (OON) provider.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.

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 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 ophthalmology services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve out-of-network services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network tertiary level care providers available to you that specialize in the care and treatment for your condition.

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. 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 a second opinion to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.

You asked the Plan to pre-approve continued SNF care. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the 100-day limit for inpatient services in a skilled nursing facility during your benefit period has been reached.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that you received 100 days of SNF care during the benefit period. The Plan has covered 100 days of SNF care.

Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider.

You asked the Plan to waive the copayment for an x-ray. You say that you do not know why this Plan is not picking up the rest of these costs. 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 $60 copayment for outpatient diagnostic tests/x-rays.

You have been asked to pay $25 which is less than your copayment amount of $60 for an x-ray. An x-ray falls within the outpatient diagnostic tests/x-rays 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 x-ray provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer system surgery.

You asked the Plan to pre-approve interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (22870).

You say that the enrollee needs this procedure for pain relief. The Plan denied your request. The Plan says this procedure is unproven and not medically necessary due to insufficient evidence of efficacy.

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 interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (22870).

Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the 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 interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer system surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2330), the extractions (D7140 x 2), and the partial upper denture (D5211) provided on December 16, 2020.

You asked the Plan to pay for the dental services. You say that your poor oral health was affecting your physical health. You say that you cannot afford this dental bill. You say that you felt it was misleading that your insurance card was dated November 5, 2020. You also say that you thought this was the effective date. The Plan denied your request. The Plan says 1 filling is covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan says that extraction is not listed as a covered service. The Plan also says that partial upper denture is not listed as a covered 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage and the filling is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the filling that you received on December 12, 2020. Additionally, the extractions and partial upper denture are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filling (D2330), the extractions (D7140 x 2), and the partial upper denture (D5211) provided on December 16, 2020.

Your complaint about being misled by your insurance card 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 2, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 laboratory 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 laboratory services provided on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the ophthalmological comprehensive medical examination (92004) and determination of refractive state (92015) provided August 3, 2020.

You asked the Plan to provide reimbursement for the ophthalmological comprehensive medical examination and determination of refractive state. You say that you would like your claim forwarded to the Plan's vision provider and reimbursement issued. The Plan denied your request. The Plan says that the eye exam has already been applied to your deductible and the refraction does not meet criteria for coverage under original Medicare and the claim must be submitted by you or the provider to the Plan's optical 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's third-party vision vendor may cover refractions when seeing a non-contract provider when the claim form and itemized receipt are submitted to the vision vendor. 

We looked at the file and the Plan's rules. The Plan has already processed the claim for the eye exam and appropriately applied the amount to your remaining deductible. Neither you nor the vision provider have submitted the claim form and itemized receipt to the third-party vision vendor for the refraction. Based on this information, we decided that the Plan's rules for coverage of the determination of refractive state have not been met. Therefore, we decided that the Plan does not have to provide reimbursement for the ophthalmological comprehensive medical examination (92004) and determination of refractive state (92015) provided August 3, 2020.

Your complaint about your claim not being forwarded to the appropriate vendor 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 24, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you may be required to use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-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 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 physician's 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 physician's services provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment purchased August 25, 2020, to October 5, 2020, from providers not certified with Medicare.

You asked the Plan to pay for the durable medical equipment. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained before you purchased these items.

The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met as both providers are not certified with Medicare. Therefore, we decided that the Plan does not have to pay for the durable medical equipment purchased August 25, 2020, to October 5, 2020, from providers not certified with Medicare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on October 20, 2020.

You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 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 outpatient services provided on October 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on April 3, 2019.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you would like reconsideration because you did not receive the member's benefit determination timely. The Plan denied your request. The Plan says this claim was not submitted within 12 months.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the psychiatric diagnostic evaluation was not filed until October 7, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on April 3, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for Skilled Nursing Facility services provided on October 22, 2020, through October 31, 2020.

You asked the Plan to pay for the Skilled Nursing Facility services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the Patient Driven Payment Model (PDPM) is inconsistent with the services that were authorized.

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, the Plan has failed to identify a substantive reason as to why the actual PDPM billed was incorrect based on the member's condition. Therefore, we decided that the Plan has to pay for Skilled Nursing Facility services provided on October 22, 2020, through October 31, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311).

You asked the Plan to pre-approve an expandable controller. You say that the expandable controller is medically necessary. The Plan denied your request. The Plan says the expandable controller is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that an expandable controller is medically necessary when the criteria cited in the Medicare rules section has been met. 

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 an expandable controller. Our reviewer says that the requested items are not medically reasonable and necessary. Our physician reviewer found the patient is a 61-year-old female who was approved for a Group 3 power wheelchair. The documentation does not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient's strength and function in the upper extremities with the ability to feed herself independently indicates that the patient can control any power options through their own individual switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311).