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

We decided that the Plan does not have to pay for an ophthalmological medical examination and evaluation
provided on September 9, 2019.
You asked the Plan to pay for the ophthalmological medical examination and evaluation. You say that the
enrollee was in an assisted living facility and could not choose an in-network optometrist as your providers
have an exclusive contract with the assisted living facility. The Plan denied your request. The Plan says nonemergent,
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 an ophthalmological medical examination and evaluation
provided on September 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis
You asked the Plan to pre-approve the Restasis. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy with the plan, and not a prescription drug plan. The Plan says that drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Restasis
Benefits for the Restasis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20 chiropractor visits to be provided by the out of network
provider.
You asked the Plan to pre-approve 20 chiropractor visits. You say that you would like to continue being treated
by this provider. The Plan denied your request. The Plan says there are in-network providers that are able to
provide this care. Therefore, coverage criteria has not been met.
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 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 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
20 chiropractor visits to be provided by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 4, 2019
You asked the Plan to pay for laboratory tests. You say that the Plan is obligated to pay for medically necessary services. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on June 4, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 6, 2019 by the out of network provider.
You asked the Plan to pay for office visit. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 6, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies provided from August 2, 2019 to October 21, 2019.
You asked the Plan to pay for diabetic supplies. You say that you are appealing with additional information. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the delivery ticket submitted did not include the carrier's tracking number and the proof of delivery did not include information to corroborate the delivery ticket submitted.
The Plan must follow Medicare rules. Medicare rules say that the supplier must furnish to the Plan sufficient information to determine whether payment is due for a claim. Information submitted by the supplier must corroborate the documentation in the medical record and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The delivery ticket submitted in the record does not corroborate delivery of these supplies to this beneficiary as billed on this claim. Based on this information, we decided that Medicare rules for coverage of diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay for diabetic supplies provided from August 2, 2019 to October 21, 2019.
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 the SNF services. You say that a SNF admission is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services needed at the current inpatient rehabilitation center he is in.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 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 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 eyewear provided to the enrollee by an out-of-network
provider on May 28, 2019.
You asked the Plan to pay for the eyewear. You say that nowhere in that book is there a definition of a "plan
optical facility" and in the Provider Directory, there are no listings for any "plan optical facility". The Plan
denied your request. The Plan says the enrollee does 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.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the eyewear have not been met. The provider is not contracted with the Plan. The enrollee's EOC
clearly states, the Plan provides a $150 allowance once every 24 months for you to use toward the purchase
price of eyewear from a plan optical facility when a physician or optometrist prescribes an eyeglass or contact
lens for vision correction. Therefore, we decided that the Plan does not have to pay for the eyewear provided to
the enrollee by an out-of-network provider on May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 18, 2019 by the out of network provider.
You asked the Plan to pay for office visit and services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says there are multiple in-network providers available within 30 miles of the member's residence that could have rendered 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 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 18, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 11, 2019 by out of network provider, "the provider". You asked the Plan to pay fora non-invasive ear/pulse oximetry monitor. You say that the doctor gave Healthcare authorization.The Plan denied your request. The Plan says no prior authorization was obtained 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 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 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 forthe medical services provided on June 11, 2019 by out of network provider, "the provider".
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis provided on August 27, 2019.
You asked the Plan to pay for dialysis. You say that you should receive $240.57 per treatment. You say that the claims should be reprocessed and paid accordingly. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for dialysis provided on August 27, 2019.
We know that your original appeal request to the Plan included dates of service August 6, 2019 and August 8, 2019. The Plan informed us that the dialysis provided on August 6, 2019 and August 8, 2019 is being handled separately. Please contact the Plan directly for more information on these dates.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on August 21, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that there was no plan of care provided. You say that this was a routine eye exam. The Plan denied your request. The Plan says the copayment applied correctly.
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 an eye exam to diagnose and treat diseases and conditions of the eye at an in-network provider. You have been asked to pay a $50 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that this was a medical eye exam. 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 the eye exam provided on August 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on July 31, 2019.
You asked the Plan to waive the copayment for the endoscopy. You say that you were authorized to use the program. You say that they should be responsible for charges. The Plan denied your request. The Plan says the copayment applied correctly.
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 $400 copayment for all other outpatient services including observation and outpatient surgical services not provided in an ambulatory surgical center. You have been asked to pay a $400 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the endoscopy provided on July 31, 2019.
Please note that this decision is only for your Medicare benefits. For any questions regarding billing the VA, contact the Plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee has a subsequent electrolyte
abnormality. The Plan denied your request. The Plan says the enrollee is medically stable, and does not require
an intensive, multi-disciplinary approach to therapy.
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 physician reviewer found
that the enrollee has increased dyspnea at rest, and upon minimal exertion. She was at contact guard assist for
toilet transfers, and minimal assist for toileting. 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 in an IRF. The documentation does not reveal that the enrollee is medically stable for
transfer to a rehab floor. She continues to be on BIPAP, has crackles in her lungs, has had recent increase in
Aldactone, and has blood pressure fluctuations and dizziness in therapy. The enrollee may benefit and
participate in additional physical and occupational therapy, but the documentation does not reveal she can
tolerate this on an intensive rehabilitation facility therapy program 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 for the enrollee.
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 the services are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 there is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at a skilled nursing facility (SNF) level. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on September 26, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that your CT scan during the emergency visit was less. You say that the Plan should cover the copayment. The Plan denied your request. The Plan says the copayment applied correctly.
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 $195 copayment for advanced imaging services at an in-network outpatient hospital. You have been asked to pay a $195 copayment for the CT scan. The CT scan falls 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 copayment for the CT scan provided on September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on June 26, 2019.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says hearing aids must be provided by the provider to be covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through the provider. We looked at the file and the Plan's rules. The requested provider in this case is not a network hearing aid provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on June 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested
admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested
admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 admission to a skilled nursing facility
(SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the
enrollee had a right open reduction internal fixation (ORIF) of the femur on 12/1/19. The enrollee admitted to
SNF on 12/4/19 and was discharged from the SNF on 1/4/20. The enrollee readmitted to an acute care hospital
on 1/9/20 with weakness. From a nursing perspective, the enrollee received oral medications. The enrollee had
stable vital signs. She had routine foley catheter care. She was treated for pain with effect. Regarding
rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital.
The enrollee was at a moderate assist level with bed mobility and transfers. She was non-weight bearing to her
right lower extremity.
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of admission to a skilled nursing facility (SNF) have not been met. Therefore, we
decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).