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

We decided that the Plan does not have to pay forthe Hepatitis A vaccine rendered on September 5, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the vaccine is not covered.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services.Therefore, we decided that the Plan does not have to pay forthe Hepatitis A vaccine rendered on September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient vision services provided April 1, 2019.You asked the Plan to waive the copayment forthe outpatient vision services. You say that you just get the routine things to make sure you're not losing eyesight with age. You continue to believe that you should not be charged for this.The Plandenied your request. The Plan says the claim processed correctly and the correct cost share 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 andcoinsurance). Your contract with the Plan clearly says that you must pay $50 copayment for Medicare covered eye exams to diagnose and treat diseases and conditions of the eyes. You have been asked to pay $50 copayment for the outpatient vision services.The outpatient vision services fall within the Vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe outpatient vision services provided April 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance services provided on November 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the ambulance services. You say that reimbursement in the amount of $0 is not acceptable. This was a medical necessary transport. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 non-emergency ambulance services provided on November 6, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered to the enrollee by the physician on July 2, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the provider type is not payable.
The Plan must follow Medicare rules. The rules say that when different physicians in a group practice
participate in the care of the patient, the group bills for the entire global package if the physicians reassign
benefits to the group.
We looked at the file and Medicare rules. The file shows that the Plan paid for the surgical services to the
primary surgeon. Separate payment to a surgeon within the same group practice is not covered. Therefore, we
decided that the Plan does not have to pay for the surgical services rendered to the enrollee on July 2, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from May 8, 2019 through May 23, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier (emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from May 8, 2019 through May 23, 2019.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 orif 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 progressive lenses (V2781) and photochromatic lenses (V2744) provided September 18, 2019.
You asked the Plan to pay for the lenses. You say that you have already paid $240 for the lenses and cannot afford to pay more. The Plan denied your request. The Plan says the requested services are not covered under the plan 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 Plan covers these services when the plan covers up to $100 for eyeglasses frames and lenses (single vision, lined bifocal or lined trifocal).
We looked at the file and the Plan's rules. lens options or enhancements are not covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the lenses have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781) and photochromatic lenses (V2744) provided September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet-rich plasma (PRP) injections to the ankle described by Category III CPT code 0232T.
You asked the Plan to pre-approve the PRP injections. You say that you feel that the plan should cover this treatment. The Plan denied your request. The Plan says Medicare does not provide coverage for PRP injections at this time.
The Plan must follow Medicare rules. Medicare rules say that Category III codes such as the code which described PRP injections are considered not medically reasonable and necessary unless sufficient evidence is presented to support that coverage should be allowed. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PRP injections have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet-rich plasma (PRP) injections to the ankle described by Category III CPT code 0232T.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospitalcare provided from September 15, 2019 through September 16, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked ourphysician 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the continued stay after September 14, 2019 was medically necessary. The record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergencydepartment (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from September 15, 2019 through September 16, 2019.
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 forthe hearing aids purchased August 7, 2019.You asked the Plan to pay forthe hearing aids. You say that it is very confusing to offer out of network coverage for hearing aids, but then restrict the vendor network.The Plan denied your request. The Plan says hearing benefit is not covered when the services are not ordered through the designated vendors.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 hearing aids are covered when purchased through hi HealthInnovations or Epic Hearing. The health plan contract specifically says hearing aids ordered through providers other than EPIC Hearing or hi HealthInnovations are not covered. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage ofthe hearing aids have not been met.Therefore, we decided that the Plan does not have to pay forthe hearing aids purchased August 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Spectroscopy (MRS) (76390).You asked the Plan to pre-approvethe MRS. You say that the service is medically necessary to determine changes of a brain lesion.The Plan denied your request. The Plan says the service at issue is not a covered benefit under Medicare.The Plan must follow Medicare rules. Medicare rules say that evidence is not adequate to conclude that MRS is reasonable and necessary, and therefore it is non-covered. We looked at the file and Medicare rules. The service at issue is not a covered Medicare benefit. Based on this information, we decided that Medicare rules for coverage of the MRS have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Spectroscopy (MRS) (76390).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services (90791) provided October 21, 2019.
You asked the Plan to pre-approve the outpatient mental health services. You say that services were medically necessary. The Plan denied your request. The Plan says the provider is not eligible to receive Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that Marriage and Family Therapists (MFT's) are not eligible for enrollment in the Medicare program.. We looked at the file and Medicare rules. The service at issue was provided by an MFT. MFT's are not eligible for Medicare reimbursement. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health services (90791) provided October 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea low dose computed tomography (LDCT) scan for lung cancer screening (G0297).You asked the Plan to pre-approvean LDCT scan for lung cancer screening. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coveragecriteria has not been met.The Plan must follow Medicare rules. Medicare rules say that lung cancer screening with LDCT is covered when specific criteria is met. We looked at the file and Medicare rules. Specifically, the enrollee does not fall within the required age range. Based on this information, we decided that Medicare rules for coverage of an LDCT scan for lung cancer screening have not been met.Therefore, we decided that the Plan does not have to pre-approvea low dose computed tomography (LDCT) scan for lung cancer screening (G0297).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forEmergency Room services provided September 22, 2019.You asked the Plan to pay forthe emergency room services. You say that services were medically necessary.The Plan denied your request. The Plan says Original Medicare is liable for payment for the services at issue.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 forEmergency Room services provided September 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient alcohol rehabilitation care beyond February 18, 2020.You asked the Plan to pre-approve the continued inpatient care. You say that you believe that ongoing care is needed at this level.The Plan denied your request. The Plan says the enrollee's needs can be met in a less intensive setting.The Plan follows Medicare rules. Medicare rules say that inpatient alcohol rehabilitation services are covered by Medicare only when reasonable and necessary based on the above referenced criteria. 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 continued inpatient care. Our reviewer says that continued inpatient care is not shown to be medically reasonable and necessary. Our physician reviewer found this 69-year-old female was admitted to the acute inpatient psychiatric/detoxification /detoxification hospitalization on February 12, 2020 with Alcohol Use Disorder with Withdrawal Unspecified and Generalized Anxiety Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was compliant with treatment and not showing any active withdrawal symptoms. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. The health plan's denial of continued inpatient psychiatric services is appropriate.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 continued inpatient care have not been met.Therefore, we decided that the Plan does not have to pre-approve continued inpatient alcohol rehabilitation care beyond February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from September 6, 2019 through September 11, 2019 provided by an in-network provider.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the servicesyou received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on September 6, 2019 and discharged on September 11, 2019. You were asked to pay a $360 copayment per day from September 6, 2019 through September 10, 2019, days 1-5 of your inpatient hospital care. You were discharged on September 11, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $360 copayment per day required for days 1-5. 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 forinpatient hospital care from September 6, 2019 through September 11, 2019 provided by an in-network provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve factor II and factor V (F2/F5) genetic testing.
You asked the Plan to pre-approve the F2/F5 genetic testing. You say that you believe that this testing is needed. The Plan denied your request. The Plan says this is not considered medically necessary according to Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that F2/F5 genetic testing is not shown to be clinically efficacious and is not covered. Therefore, we decided that the Plan does not have to pre-approve factor II and factor V (F2/F5) genetic testing.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 12, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency 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 to the enrollee by an out-of-network provider on September 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgical services provided to the enrollee on August 5, 2019.You asked the Plan to pay forthe assistant surgical services. The Plan denied your request. The Plan says this type of provide is not eligible for payment for assistant surgeon services.The Plan follows Medicare rules. The rules say that Medicare onlypays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay forthe assistant surgical services provided to the enrollee on August 5, 2019.
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 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 documentation does not reveal that the enrollee required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee does not require 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 28, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 physician's services provided on May 28, 2019.