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

We decided that the Plan does not have to pre-approve 4 additional acupuncture office visits.
You asked the Plan to pre-approve the acupuncture visits. You say that you feel that this should not be denied. You have several injuries and acupuncture works for you. The Plan denied your request. The Plan says additional visits is not medically necessary as the enrollee has reached the maximum benefit from his care.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 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 acupuncture visits. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found the documentation indicates that shows that the enrollee has reached maximum benefit from the current treatment. His complaints are neither improving nor getting worse. The requested 4 additional acupuncture visits are not medically reasonable and 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 acupuncture visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional acupuncture office visits.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse $200 for the eyewear purchased on December 3, 2019 from an out-of-network provider.
You asked the Plan to reimburse $200 for the eyewear. You say that you were aware the provider was out-of-network, but you received your eyewear at reasonable prices there. The Plan denied your request. The Plan says that you do not have out-of-network benefits.
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 supplemental vision benefit is not a Medicare benefit. It is a supplemental benefit offered by the plan that reimburses $200 toward your purchase of lenses/frames and contact lenses. This means that the generic lock-in language in Chapter 3 is not sufficient. The limitation on a plan provider must be specifically listed for the supplemental vision care benefit. It is not, neither in the vision care section of the benefits chart (Chapter 4) nor in the exclusions list at the end of the benefit chart. The Plan must reimburse $200 toward your purchase of lenses/frames and contact lenses. Therefore, we decided that the Plan has to reimburse $200 for the eyewear purchased on December 3, 2019 from an out-of-network 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (CPT Code 92015) provided on November 25, 2019.
You asked the Plan to pay for the service. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit.
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.
We looked at the file and the Plan's rules. You exhausted your benefit, because you received the same services on March 20, 2019. Your EOC clearly states, Routine Eye Exam: Limited to one (1) exam every year. Therefore, we decided that the Plan does not have to pay for determination of refractive state (CPT Code 92015) provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 6, 2019, and October 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on May 6, 2019, and October 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a Cxbladder monitor lab test (0013M) provided on November 14, 2019.
You asked the Plan to pay for the Cxbladder monitor test. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is not a Medicare covered benefit.
The Plan must follow Medicare rules. Medicare rules say that that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Cxbladder monitor test have not been met. Specifically, per Local Coverage Determination Biomarkers for Oncology (L35396), this test is non-covered. Therefore, we decided that the Plan does not have to pay for a Cxbladder monitor lab test (0013M) provided on November 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical condition that requires a lot of monitoring and treatment by a doctor.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from PT and OT but the documentation does not indicate that the enrollee's functional level requires this on an intensive level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve the dental item. The Plan denied your request. The Plan says that the request for the upper denture exceeds the frequency limit of one every 5 years.
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. The record shows that there was a predetermination request submitted by the provider on January 7, 2020. However, the Plan has not provided evidence that the enrollee actually received the dentures. Therefore, we decided that the Plan has to pre-approve a complete upper denture (D5110).
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and BRCA2 testing.
You asked the Plan to pre-approve the BRCA 1 and BRCA2 testing. You say that the enrollee has a strong family history of breast cancer and a mammogram provided on March 27, 2020 came back abnormal. The Plan denied your request. The Plan says there is no information showing that the enrollee has a personal history or diagnosis of any of the types of cancer for which this testing is covered.
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 BRCA 1 and BRCA2 testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have a dense spot on her breast and a family history of breast cancer. The enrollee does not have a personal history of breast, ovarian or pancreatic cancer.
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 BRCA 1 and BRCA2 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA 1 and BRCA2 testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted for hypoxic respiratory failure. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs respiratory support including tracheostomy care, infectious disease precautions, secretion care, tube feedings, surveillance laboratory studies, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient (CPT Code 97810) provided on November 22, 2019 by an out-of-network provider.
You asked the Plan to pay for acupuncture. You say that you had acupuncture before with an out-of-network provider and it was covered. The Plan denied your request. The Plan says you chose this provider on your own and were not referred by a participating provider.
The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers acupuncture only when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acupuncture have not been met. The provider is not in-network and your EOC clearly states, out-of-network acupuncture is not covered. Therefore, we decided that the Plan does not have to pay for acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient (CPT Code 97810) provided on November 22, 2019 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on April 1, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says based on the attached clinical, the testing was not completed.
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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found according to the lab report, the testing was not performed. Therefore, the billing is not supported. 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 pay for lab services provided to the enrollee on April 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 2, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were medically necessary. The Plan denied your request. The Plan says there is no valid referral for this service.
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 has network providers available who can provide 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 medical services provided on September 17, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99291) provided to the enrollee on August 3, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says CPT 99291 remains not supported.
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 99291 is "Critical care, evaluation and management of the critically ill or critically injures patient, first 30-74 minutes." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found no note for the DOS in question has been submitted for review. Therefore, the billing of CPT 99291 on 8/3/2019 is not supported. 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 pay for critical care services (CPT 99291) provided to the enrollee on August 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frame (V2025), progressive lens, per lens (V2781), tint, photochromatic, per lens (V2744) and anti-reflective coating, per lens (V2750) provided on December 2, 2019.
You asked the Plan to pay for the eyewear. You say that you were told that you could go outside the network and still have coverage. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
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. We looked at the file and the Plan's rules. You do have additional vision benefits with your plan, however, the services already paid at the maximum rate allowed by the plan. Per the 2019 EOC, you are responsible for $0
copayment for routine eye wear and receives a total credit of $100 toward purchase of lenses/frames and contact lenses. After Plan paid benefits for eyeglasses (lenses and frames) or contact lenses, the member is responsible. The plan paid $79.72 for service code V2020 (standard frame) and $20.28 for service code V2203 (standard lens). You received non-covered vision items, V2025 (Deluxe frames), V2781 (Progressive lens, per lens), V2744 (Tint, photochromatic, per lens) and V2750 (Antireflective coating, per lens). Per your benefits in the 2019 EOC, the plan will cover all medical services that are medically necessary, are listed in the plan's Medical Benefits Chart, and are obtained consistent with the plan rules. You already received the maximum credit of $100 toward purchase of lenses/frames and any additional amounts/items are not covered by Medicare, nor are they covered by the plan. Hence, you are responsible for the remaining cost of the vision items and the non-covered items in the combined amount of $418. Therefore, we decided that the Plan does not have to pay for deluxe frame (V2025), progressive lens, per lens (V2781), tint, photochromatic, per lens (V2744) and anti-reflective coating, per lens (V2750) provided on December 2, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.
You asked the Plan to pre-approve Genvisc. You say that the requested Genvisc is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc AND Monovisc first.
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 Genvisc. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of Bilateral primary osteoarthritis of the knees. The Plan requires a trial of Orthovisc AND Monovisc first, before they will approve Genvisc. The documentation does not show that the enrollee has tried and failed the preferred drugs. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc.