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

We decided that the Plan does not have to pay for lab work provided on December 11, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that
the member's primary care physician did not refer 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 lab work provided on December 11, 2019 by an
out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on November 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 lab tests provided on November 22, 2019 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) services.
You asked the Plan to pre-approve SNF services. You say that these services are necessary for you. The Plan denied your request. The Plan says that you no longer require the daily skilled care of a professional therapist or licensed nurse but require custodial level of care.
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 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 continued 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 continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumpectomy provided on February 18, 2020.
You asked the Plan to waive the copayment for the lumpectomy. You say that you would like the $225 copayment waived because you were told there would be one copayment for the surgery itself regardless of the number of procedures. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $225 copayment for the lumpectomy. The lumpectomy 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 lumpectomy provided on February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you do not have unstable, complex medical or intensive rehabilitation needs requiring supervision by a rehabilitation physician and an intensive and coordinated interdisciplinary team in a resource intensive inpatient hospital environment.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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. There is concernthat you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are 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 the documentation supports that you are now medically stable. While you are reasonably expected to benefit from continuingphysical therapy (PT) and occupational therapy (OT), there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 24, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous and/or interlaminar device (22869, 22870).
You asked the Plan to pre-approve an interspinous and/or interlaminar device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 an interspinous and/or interlaminar device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research is needed. 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 interspinous and/or interlaminar device have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous and/or interlaminar device (22869, 22870).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the fingertip pulse oximeter and surgical masks purchased on April 2, 2020.
You asked the Plan to reimburse you for the supplies. You say that these supplies are medically necessary. The Plan denied your request. The Plan says the provider is not Medicare certified.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. Payment cannot be made for items purchased from this provider because this provider is not a medical provider and is not enrolled in Medicare. Therefore, we decided that the Plan does not have to reimburse you for the fingertip pulse oximeter and surgical masks purchased on April 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Lumbar Vertiflex Interspinous Spacer device.
You asked the Plan to pre-approve a Lumbar Vertiflex Interspinous Spacer device. You say that the requested
Lumbar Vertiflex Interspinous Spacer device is medically necessary. The Plan denied your request. The Plan
says the requested Lumbar Vertiflex Interspinous Spacer device 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 a Lumbar Vertiflex Interspinous Spacer
device. Our reviewer says that the requested Lumbar Vertiflex Interspinous Spacer device is not medically
necessary. Our physician reviewer found the enrollee is with history of low back pain radiating down bilateral
lower extremities to her knees. The lumbar spacer is experimental. More research is needed to show safety and
efficacy. The requested lumbar spacer is not medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Lumbar Vertiflex Interspinous Spacer device have not been met. Therefore,
we decided that the Plan does not have to pre-approve a Lumbar Vertiflex Interspinous Spacer device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysyour condition can be taken care of at home with home health.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 you were medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. Though you need PT and OT, you will not do well with IRF level of therapies. You may benefit from further PT and OT but does not require an intensive therapy program. IRF admission is not medically necessary based on your current and medical stability.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal provided on January 13, 2020.You asked the Plan to waive the copayment for the colonoscopy with lesion removal. You say that you were told the colonoscopy was preventive and there would be no out-of-pocket cost. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $235 copayment for surgery services at an in-network ambulatory surgical center. You have been asked to pay a $235 copayment for the colonoscopy with lesion removal. The colonoscopy with lesion removal falls within the surgery "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows a diagnosis of benign neoplasms of colon which makes the colonoscopy with lesion removal surgical in nature.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 colonoscopy with lesion removal provided on January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the documentation received does not indicate that the enrollee requires the level of
intensity of therapy, nor has complex medical problems requiring daily physician oversight.
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 enrollee was medically stable with no evidence of need for supervision by PMR
Physician or needs acute rehab nursing care. Functionally, she needs PT and OT but does not require IRF level
of therapies. The enrollee may benefit from further PT and OT but does not require an intensive therapy
program. IRF admission is not medically necessary based on the patient's current functional status and lack of
medical complexity.
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction (92015) services provided March 3, 2020.
You asked the Plan to pay for the vision services. You say that this provider is listed an the plan's provider directory and you feel that this should be covered. The Plan denied your request. The Plan says refraction services are not covered unless rendered by a participating routine vision care 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 rendered as a port of a routine eye exam by a participating routine vision care provider. The provider is in network under medical but is not in network as a routine vision care provider with the vision benefit vendor. We looked at the file and the Plan's rules. Refraction services are covered when completed by a participating routine vision care provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for refraction (92015) services provided March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on November 21, 2019.You asked the Plan to pay forthe extraction. You say that there was an abscess,so it had to be pulled. You say that you are owed over $300.The Plan denied your request. The Plan says only 2 extractions are covered per calendar year.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan also has a maximum benefit of 2 extractions per calendar year. The Plan paid for 2 extractions provided on June 4, 2019, which exhausted your benefit.Therefore, we decided that the Plan does not have to pay for the extraction provided on November 21, 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 the records provided support the need for IRF care.The Plan denied your request. The Plan says the records do not show the need to be seen by a rehab doctor three times a week or a multidisciplinary team approach for care. The Plan says that the enrollee can safely receive the services needed in another setting.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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treatment of hip fracture after a fall. All medical problems are stable and do not require ongoing inpatient management. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does have a documented need for physical therapy but the documentation does not support a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair.You asked the Plan to pre-approve the seat lift mechanism of a seat lift chair. You say that the enrollee has had several issues due to trying to rise up to use the bathroom.The Plan denied your request. The Plan says criteria for the seat lift mechanism of a seat lift chair is not met.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.We looked at the file and Medicare rules. There is no documentation of severe arthritis of the hip or knee, a physician's course of treatment with a lift chair, or that the enrollee is completely incapable of standing up from a regular armchair. Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism of a seat lift chair have not been met.Therefore, we decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair.