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

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on December 30, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that your physician provided medically necessary services to the enrollee in good faith. In consideration for the services rendered, your doctor is seeking reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 had network providers available who could have provided 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 subsequent nursing facility care (99308) provided on December 30, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April
10, 2020.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on February 10, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the medical records support the primary reason for the visit was diagnostic. Refraction exams are routine and are not covered for diagnostic purposes.
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 this service have not been met. Specifically, the eye refraction was provided for a diagnostic purpose, not for a routine eye exam. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with a specialist (92004) to be provided
by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that you would like to see this out-of-network
provider. The Plan denied your request. The Plan says there are in-network providers available 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The records provided for review do not
show that the services at issue are urgent or emergent. 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 an office
visit with a specialist (92004) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an astigmatism-correcting intraocular lens (V2787) provided on October 5, 2020.
You asked the Plan to pay for an astigmatism-correcting intraocular lens. You say that you should be reimbursed because over the long haul the Plan would need to pay less to correct your astigmatism. The Plan denied your request. The Plan says rules for payment have not been met because the item at issue is not a Medicare or Plan benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL.
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatismcorrecting
feature of an IOL. Therefore, we decided that the Plan does not have to pay for an astigmatismcorrecting
intraocular lens (V2787) provided on October 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from August 15,
2020 to August 22, 2020.
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 records do not support the billing of DRG 252 and diagnosis code E11.52.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 252 and diagnosis code E11.52 (type 2
diabetes mellitus). 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 these services. Our
reviewer says that the records do not support the billing of DRG 252 and diagnosis code E11.52. Our physician
reviewer found the enrollee was admitted to the hospital with diabetic peripheral artery disease (PAD) needing
vascular intervention. He has Diabetic Chronic kidney disease (CKD) 2 at baseline and no baseline creatinine
was noted in the documentation. There is no noted hypotension noted but a drop in hemoglobin postoperatively.
The records do not support the billed DRG and diagnosis code.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital services rendered from August 15, 2020 to August 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation hospital stay from March 3, 2021, to March 10, 2021.

You asked the Plan to waive the copayment for the inpatient rehabilitation hospital stay. You say that you were transferred, not released from the hospital and should not be charged a second copay for the rehabilitation stay. The Plan denied your request. The Plan says you were formally discharged to a different level of care on March 3, 2021, and a new copay applies to this different level of care.

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 $300 copayment per day, days 1-6 for inpatient hospital care. Your inpatient hospital cost sharing will apply each time you are admitted. This includes when transferring from one facility to another or within the same facility between levels of care.

You have been asked to pay a total of $1,800 ($300 copayment x 6 days = $1,800) for the inpatient rehabilitation hospital stay. This service falls within the Inpatient hospital 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 for the inpatient rehabilitation hospital stay from March 3, 2021, to March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for contact lenses provided on February 20, 2020.
You asked the Plan to reimburse you for the contact lenses. The Plan denied your request. The Plan says you must use a Plan provider for coverage of the routine eyewear allowance.
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 provided by a Plan provider. We looked at the file and the Plan's rules. The file shows that the provider at issue in this case is not a Plan provider. Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, we decided that the Plan does not have to reimburse you for contact lenses provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear you received on May 13, 2020.
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says only one pair of
glasses is covered.
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 one pair of eyeglasses up to $150 per year.
We looked at the file and the Plan's rules. The records show that you received two pairs of eyeglasses on the
date of service in question. The Plan only covers one pair per calendar year. The second pair exceeds the
benefit limit and is not covered. Based on this information, we decided that the Plan's rules for coverage of the
eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear you
received on May 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided by an opted-out dentist on November 20, 2020.
You asked the Plan to pay for dental services. You say that the Plan has paid your claims in the past for many dental procedures. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider has opted out of Medicare coverage and is not payable.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental services provided by an opted-out dentist on November 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra drops, ophthalmic solution.
You asked the Plan to pre-approve Xiidra Dro 5%. You say that the enrollee has been stable on Xiidra since prescribed. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug benefit.
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 Xiidra drops, ophthalmic solution.
Benefits for Xiidra Dro 5% 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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 LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate.
You asked the Plan to pre-approve Methotrexate. The Plan denied your request. The Plan says this is not covered under the enrollee's Part B plan.
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 Methotrexate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), cone beam computed tomography (CT) image capture with limited field of view - less than one whole jaw (D0380), consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310), unspecified preventive procedure, by report (D1999), core buildup, including any pins when required (D2950), and endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided January 20, 2021, and February 1, 2021.

You asked the Plan to pay for the intraoral x-rays, cone beam CT scan, dental consultation, unspecified preventative procedure, core buildup and endodontic therapy. You say that you had difficulty finding a network dentist and a plan representative told you that you could go out-of-network. The Plan denied your request. The Plan says a review of the customer service phone call found that you were told that a pre-approval for the services needed to be requested for the out-of-network dentist prior to being received. The provider in this case is not part of the Plan's network and pre-approval was not obtained therefore the services are not covered.

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. The Plan covers certain dental services when received by a participating provider. 

We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. Based on this information, we decided that the Plan's rules for coverage of the intraoral x-rays, cone beam CT scan, dental consultation, unspecified preventative procedure, core buildup and endodontic therapy have not been met. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), cone beam computed tomography (CT) image capture with limited field of view - less than one whole jaw (D0380), consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310), unspecified preventive procedure, by report (D1999), core buildup, including any pins when required (D2950), and endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided January 20, 2021, and February 1, 2021.

Your complaint about difficulties finding a network provider and potentially receiving confusing or incorrect information from plan representatives is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx testing provided on January 6, 2021.
You asked the Plan to pay for the FoundationOne CDx testing. You say that you would like reconsideration because this testing was medically necessary and is covered by Medicare. The Plan denied your request. The Plan says the provider did not submit prior authorization as required of contracted providers.
The Plan must follow Medicare rules. Medicare rules say that NGS testing may be covered when specific criteria are met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the FoundationOne CDx testing have not been met. Specifically, the record does not include sufficient information to determine why this testing was ordered or how it will affect the member's treatment. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx testing provided on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation provided on August 29, 2021.
You asked the Plan to pay for the consultation. You say that the denial is not fair and the consultation should be covered. The Plan denied your request. The Plan says this service is not covered.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation provided on August 29, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient services provided from August 28, 2020, through August 31, 2020 with the reported principal diagnosis G92, Acute Metabolic Toxic Encephalopathy (DRG 091).

You asked the Plan to pay for inpatient services provided from August 28, 2020, through August 31, 2020 with the reported principal diagnosis G92, Acute Metabolic Toxic Encephalopathy. The Plan denied your request. The Plan says that the records submitted do not support the diagnosis of DRG 091. The claim was paid with DRG 069.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with the principal diagnosis G92, Acute Metabolic Toxic Encephalopathy. 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 inpatient services provided with the reported principal diagnosis G92, Acute Metabolic Toxic Encephalopathy. Our reviewer says that the principal diagnosis code G92 is properly assigned. Our physician reviewer found that the record indicates that the enrollee was on dialysis when he became disoriented. Evaluation demonstrated early signs of pneumonia as well as altered mental status. The enrollee was hypoxic. The record indicates that the enrollee had acute metabolic encephalopathy at the time of admission. No neurologic structural abnormality was found to explain the altered mental status. The diagnosis code G92 is properly assigned. The elements of the coverage criteria are satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient services provided from August 28, 2020, through August 31, 2020 with the reported principal diagnosis G92, Acute Metabolic Toxic Encephalopathy (DRG 091).

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.