Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are 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 in the Medicare rules section. 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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing (CPT code(s): 81302, 81330, 81345, 81406, 81407, 81408, 81479) provided to the enrollee on August 22, 2020.

You asked the Plan to pay for the testing. You say that the claim should be paid.The Plan denied your request. The Plan says these services are not authorized because molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes. 

The Plan states this is not a COVID screen test.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, the testing, was requested solely for screening purposes. Medicare says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.Therefore, we decided that the Plan does not have to pay for molecular genetic screening testing (CPT code(s): 81302, 81330, 81345, 81406, 81407, 81408, 81479) provided to the enrollee on August 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care.
You asked the Plan to pay for SNF care. You say that the requested SNF care is a necessity for you. The Plan denied your request. The Plan says rules for SNF care have not been met.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on June 1, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visit consultation services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the OON consultation services. You say that your oncology specialist works closely with this OON surgeon, and that is the reason you wish to see them. The Plan denied your request. The Plan says there are in-network providers with whom you can receive consultation and second-opinion 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. We found no exception that would require the Plan to pre-approve services with an OON provider. Therefore, we decided that the Plan does not have to pre-approve office visit consultation services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing
needs. You do not have documented skilled therapy needs. You are functioning well given your current weight
bearing restriction. Daily skilled services are not required to establish a maintenance program or to prevent
deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be
provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for physical therapy visits.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no gap issue, and there are in-network providers available.
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. 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 a referral out-of-network for physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not
required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The
enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye and medical examination for diagnosis and treatment, established patient, 1 or more visits (CPT code 92014) and the eye refraction (CPT code 92015) provided on February 25, 2021.

You asked the Plan to pay for the vision care. You say that you were told by the Plan that the refraction and annual exam should be zero copayment for 2021. The Plan denied your request. The Plan says eye refractions are only covered if they are routine.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Your 2021 EOC states that eye refractions are only covered if they are routine and performed by a routine supplemental vision care provider. Your claim was billed with a diagnosis of H25.093--Other age-related incipient cataract, which is considered as a medical diagnosis. Therefore, you are responsible for the cost. Therefore, we decided that the Plan does not have to pay for the eye and medical examination for diagnosis and treatment, established patient, 1 or more visits (CPT code 92014) and the eye refraction (CPT code 92015) provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3310) provided on February 11, 2021.
You asked the Plan to pay for endodontic therapy. You say that this service was necessary and should be
covered. The Plan denied your request. The Plan says endodontic services are not covered by your dental
benefit. The services were also provided out-of-network, and the Plan does not cover out-of-network dental
care.
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
endodontic therapy (D3310) provided on February 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reimburse you the copayment for the knee x-ray provided on February 9, 2021.
You asked the Plan to reimburse you the copayment for the knee x-ray (73565). You say that you had the x-ray done in your doctor's office. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment for Outpatient Diagnostic tests. 
You have been asked to pay a $100.70 copayment for the knee x-ray (73565). The knee x-ray (73565) falls within the Outpatient Diagnostic tests benefit category. The allowed amount is $100.70 which is less you're your required copayment. 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 reimburse you the copayment for the knee x-ray provided on February 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 17, 2021, through April 18, 2021.You asked the Plan to pay for the acute inpatient hospital care. You say that went to the hospital on April 17, 2021 for severe bleeding from your rectum and other serious symptoms that needed medical attention. You say it was recommended by the hospital for you to be admitted because of your symptoms.The Plan denied your request. The Plan says the hospital stay is approved as an observation stay and does not meet Medicare criteria for an inpatient hospital stay.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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found your condition stabilized and improved and you were discharged home on April 18, 2021 with a primary care physician follow-up visit. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department 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 not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 17, 2021, through April 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the hearing aid, digital, binaural
(V5260) and dispensing fee, binaural (V5160) provided January 27, 2021.

You asked the Plan to provide additional payment for the hearing aid and dispensing fee. You say that the
dispensing fee seems like a made-up charge and you don't think it is fair you have to pay for it. The Plan denied
your request. The Plan says the cost-sharing was applied correctly.

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 up to $750 both ears combined every calendar year.

We looked at the file and the Plan's rules. In this case the Plan has covered the hearing aids up to the $750
hearing aid allowance. Therefore, we decided that the Plan does not have to provide additional payment for the
hearing aid, digital, binaural (V5260) and dispensing fee, binaural (V5160) provided January 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says Ondansetron to be administered at home is not covered under the Part B 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 Ondansetron.
Benefits for Ondansetron 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 2, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are
not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab
services provided on December 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery provided on February 3, 2021.
You asked the Plan to pay for the outpatient surgery. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says your provider has opted out of the Medicare program and payment cannot be made.
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 the outpatient surgery provided on February 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis 5MG tablet.

You asked the Plan to pre-approve the medication. You say that the enrollee has left popliteal deep vein thrombosis (DVT). The Plan denied your request. The Plan says the medication is not covered.

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 Eliquis 5MG tablet.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or
therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria
for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenetics testing services provided on January 20, 2021.
You asked the Plan to pay for the testing services. You say that the test was designed to assist in the management of neuropsychiatric patients. The Plan denied your request. The Plan says one CPT code must be submitted for the panel.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the testing panel at issue was not billed with the correct code and unit of service. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenetics testing services provided on January 20, 2021.
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 service is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for admission to an IRF.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Medically necessary services can be provided in a different 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and unspecified preventative procedure, by report (D1999) provided July 8, 2020.
You asked the Plan to pay for the periodontal maintenance and unspecified preventative procedure. You say that the Plan has previously provided reimbursement for services from the same provider. The Plan denied your request. The Plan says the services are not covered because they were rendered by a provider who has opted out of Medicare.
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 the periodontal maintenance and unspecified preventative procedure when the services are provided by a licensed dental provider who accepts Medicare patients in the United states and has not opted out of Original Medicare.
We looked at the file and Medicare rules. In this case the provider who rendered the services has opted out of Medicare. Based on this information, we decided that the Plan's rules for coverage of the periodontal maintenance and unspecified preventative procedure have not been met. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) and unspecified preventative procedure, by report (D1999) provided July 8, 2020.
Your complaint about potential inconsistencies in how the Plan covers services from this provider 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.