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

We decided that the Plan does not have to pre-approve the ophthalmology consult to be provided by out of network provider
You asked the Plan to pre-approve ophthalmology consult. You say that your vision is at risk if you do not get the eye injections but you are in Tennessee until February and needs to have the injections while you are out of town. 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 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 the ophthalmology consult to be provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits provided on February 19, 2019 by the out of network provider.
You asked the Plan to pay for office visits. You say that you cancelled your plan and went back to your original coverage. You say that you were told it was cancelled so you went to the doctor's office. You say that you then received a letter stating your plane wasn't cancelled until March. The Plan denied your request. The Plan says no prior authorization was 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 office visits provided on February 19, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee by the facility on June 20, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee by the facility on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the arthrocentesis procedures provided
from October 8, 2019 to October 29, 2019.
You asked the Plan to waive the copayments for the arthrocentesis procedures. You say that you should only be
paying a coinsurance for the injections and not for office visits. 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 $50
copayment for in-network Medicare-covered specialist services. For each date of service, you have been asked
to pay the allowed amount of the claim because these amounts are less than the $50 copayment for the
arthrocentesis procedures.
You have been asked to pay a $49.55 copayment for each of the arthrocentesis procedures. ($49.55 x 4 =
$198.20). The arthrocentesis procedures fall within the "Physician/Practitioner services, including doctor's
office visits" benefit category. The record shows that arthrocentesis is a surgical procedure that was provided in
a specialist's office.
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 copayments for the arthrocentesis procedures provided from October 8,
2019 to October 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract surgery to be provided to the enrollee at the out of network facility.
You asked the Plan to pre-approve the out-of-network services. The Plan denied your request. The Plan says the requested treatment is available in-network.
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 facility in this case is not a network facility with the Plan. The Plan has network facilities available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve cataract surgery to be provided to the enrollee at the out of network facility.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the genetic testing rendered to the enrollee by the facility on January 23, 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 that procedure codes 81230 and 81231 are not payable.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that procedure codes 81230 and 81231 have a status indicator of X and are statutorily excluded. While this is correct, the status indicator of X is for the Physician Fee Schedule, which is not applicable for the services at issue. The codes are payable based on the Lab Fee Schedule. The Plan has not provided any documentation to support that these codes are not payable as billed by the laboratory. Therefore, we decided that the Plan has to pay for the genetic testing rendered to enrollee by the facility on January 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 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: Other
Decision: Unfavorable

We decided that the Plan does not have to reimburse the enrollee for progressive lenses and deluxe lens feature provided on May 14, 2019.
You asked the Plan to reimburse the enrollee for progressive lenses and deluxe lens feature provided on
May 14, 2019. You say the eyeglass were purchased after cataract surgery and should be covered. The Plan denied your request. The Plan says this vision related services is not covered by your medical plan.
The Plan follows Medicare rules. Medicare rules say that progressive lenses (V2781) will be denied as
non-covered. Medicare rules say that deluxe lens feature (V2702) will be denied as non-covered.
We looked at the file and the Medicare rules. The file shows that the eyeglasses the enrollee purchased were needed due to post-cataract surgery.
Although post-cataract surgery standard eyeglasses are covered by Medicare, Medicare rules say that progressive lenses and deluxe lens feature are not covered. Therefore, we decided that the Plan does not have to reimburse the enrollee for progressive lenses and deluxe lens feature provided on May 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, medical necessity has not been established. Therefore, coverage criteria has not been met.
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. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 8, 2019 by the out of network provider.
You asked the Plan to pay for inpatient evaluation. You say that you are appealing with 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 for this inpatient stay was denied by the Plan.
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 August 8, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray (D0220), the core buildup (D2950), and the root canal (D3320) provided on July 1, 2019.
You asked the Plan to pay for the intraoral x-ray, core buildup, and the root canal. The Plan denied your request. The Plan says the frequency limit for intraoral x-rays has been exceeded. The Plan also says that the core buildup and root canal are not listed as covered services.
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 core build up, and root canal are not among those covered under this benefit. Additionally, the frequency limit has been exceeded for the intraoral x-rays. The record shows that you last received intraoral x-rays on January 7, 2019. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray (D0220), the core buildup (D2950), and the root canal (D3320) provided on July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on September 13, 2019 by out of network provider
You asked the Plan to pay for podiatry services. You say that there is authorization on file for all care at the facility including consultations. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the nursing facility is also out-of-network.
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 podiatry services provided on September 13, 2019 by out of network provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires respiratory management, close monitoring, and rehab therapies. The Plan denied your request. The Plan says the services are being provided in the current acute care setting already approved.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for respiratory failure and failure to thrive. The enrollee was intubated, but later extubated at an outside hospital, before being transferred to the current facility, where she has been receiving NIV and supplemental oxygen. The enrollee is noted to have a poor prognosis and Hospice has been recommended. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 1/8/20 for the treatment of prolonged recurrent Polymorphic Ventricular Tachycardia and respiratory failure requiring mechanical ventilation. An AICD was placed 1/15/2020 given recurrent ventricular arrhythmia causing Torsades. The enrollee has spent a prolonged course in the hospital and has developed critical illness myopathy. He is now motivated to improve and hemodynamically stabilizing. The enrollee is moderate assist for feeding, but maximum/total assist for all other aspects of care, including mobility and transfers. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, skin and O2 care, and daily therapy can be provided at a lower level of care. In this case, the member is mostly total/maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on August 27, 2019 by out of network provider,
You asked the Plan to pay for subsequent nursing facility care. You say that you are appealing the denial of payment for an office visit on August 27, 2019. When the physicians or nurse practitioners are called into see a patient, there is a medical necessity pre-established. You request the Health Plan to review the claim and authorize payment. The Plan denied your request. The Plan says they did not find a valid referral for this service. The services were not urgent or emergent. The enrollee must utilize in-network providers.
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 subsequent nursing facility care (99309) provided on August 27, 2019 by out of network provider
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 supports the need for IRF care. The Plan denied your request. The Plan says the clinical information does not support the IRF level of care.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. The enrollee is requiring assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy may be more appropriate and will allow for measurable gains within a predicted period. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full allowance amount forthe retainer crown (D6790), and the pontic (D6240) provided on September 6, 2019.You asked the Plan to reimburse the full allowance amount forthe dental services. You say that you should be reimbursed the full $1,000 allowance for the dental services you received. You say that you only received $829 in reimbursement. You also say that you should be reimbursed an additional $171.The Plan denied your request. The Plan says there is an allowance of $1,000 for covered dental services that you receive. The Plan says that the full allowance has already been reimbursed.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 maximum allowance of $1,000 has been reimbursed. The record shows that the Plan paid $171.05 for date of service May 23, 2019. Additionally, the Plan paid $829 towards the services provided on September 6, 2019.Therefore, we decided that the Plan does not have to reimburse the full allowance amount forthe retainer crown (D6790), and the pontic (D6240) provided on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tub stool or bench (E0245).
You asked the Plan to pre-approve tub stool or bench. You say that you recently suffered a hip injury and is afraid of falling in the bath tub. You have low income and is unable to purchase the item. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that tub stool or benches are not covered because they are not primarily medical in nature. While a tub stool or benches may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a tub stool or bench (E0245).