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

We decided that the Plan does not have to pay for eyeglasses received on December 15, 2020.

You asked the Plan to pay for eyeglasses. You say that you would like the Plan to allow you to use this provider and you want the Plan to pay the allowed amount for the item. The Plan denied your request. The Plan says The Plan says that reimbursement was denied because an out-of-network provider rendered the service.

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's network providers are utilized.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Specifically, services were provided by an out-of-network provider. The Plan has network providers available to provide these services. 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 eyeglasses received on December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and a diagnostic test provided by a participating provider on February 24, 2020, to November 25, 2020.
You asked the Plan to waive the copayment for a specialist office visit and a diagnostic test. You say that these services were all related to your surgery. You say that you would like these charges paid. The Plan denied your request. The Plan says the correct copayments have been applied.
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 $25 copayment for physician/practitioner services/specialist and a $75 copayment for outpatient diagnostic tests/diagnostic tests. You have been asked to pay a $25 copayment for a specialist office visit and a $75 copayment for a diagnostic test. The total amount you have been asked to pay is $100 ($25 + $75 = $100). A specialist office visit falls within the physician/practitioner services/specialist and a diagnostic test falls within the outpatient diagnostic tests/diagnostic tests 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 a specialist office visit and a diagnostic test provided by on February 24, 2020, to November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) received August 11, 2020 from the non-participating provider.
You asked the Plan to pay for the determination of refractive state. You say that the Plan should pay for the requested service. The Plan denied your request. The Plan says eye refractions are only covered by your plan if performed by participating provider and performed as a routine screening.
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 performed by a participating provider and performed as a routine screening. We looked at the file and the Plan's rules. This service was performed as part of a medical (non-routine) procedure. Eye refractions are only covered by your plan if performed by participating provider and performed as a routine screening. Based on this information, we decided that the Plan's rules for coverage of the determination of refractive state have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) received August 11, 2020 from the non-participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 17, 2020, to November 19, 2020.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit period from August 11, 2020, to January 28, 2021. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 17, 2020, to November 19, 2020.
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 LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have 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 that the patient is a 68-year-old female who was admitted to the current acute care hospital with acute respiratory failure. Most recent notes show that the patient's respiratory status is worsening. In this case, the patient appears to be worsening and unstable requiring additional short-term acute care services to complete workup and treatment and the stabilize the patient. The patient does not require services at the LTACH that are not already available and covered at the current facility. In addition, there are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed and the patient is more stable. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, abdomen (74019) and radiologic examination, chest (71045) provided January 17, 2021
You asked the Plan to pay for the diagnostic services. You say that the claim denied as duplicate in error. Please review and reprocess claim for reimbursement according to contract. The Plan denied your request. The Plan says exact duplicate claim/service. These codes were unbundled and were replaces with a more appropriate comprehensive code.
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 CPT code 71045 was billed and paid on another claim. CPT codes 74019 and 71045 are component services that together are represented by the comprehensive code 74022. A physician shall not report multiple codes corresponding to component services if a single comprehensive code describes the services performed. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for the radiologic examination, abdomen (74019) and radiologic examination, chest (71045) provided January 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventative procedure, by report (D1999) provided December 8, 2020.
You asked the Plan to pay for the unspecified preventative procedure. You say that you would like the Plan to pay for the services provided. The Plan denied your request. The Plan says this service is not covered under your dental benefit.
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 unspecified preventative procedure, by report (D1999) provided December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and periodontal maintenance provided on January 15, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and periodontal maintenance. You say that services provided in the past by this provider have been covered. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits.
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, you are responsible for 100% of the cost for dental services rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and periodontal maintenance provided on January 15, 2021 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.

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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has been placed in isolation due to COVID protocol but is noted to be asymptomatic. The note dated May 19, 2021 states she is ambulating and does not have a fever. She has no skilled nursing or skilled therapy needs. She does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided from December 4, 2020, through December 22, 2020.
You asked the Plan to waive the coinsurance for radiation therapy services. You say that you met your out-of-pocket expense in May. You say that the claim should be reviewed and settled. The Plan denied your request. The Plan says a previous claim reprocessed to lower your maximum out-of-pocket cost, therefore the coinsurance applied 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 20% coinsurance for radiation therapy at an in-network outpatient hospital. You have been asked to pay $317.63, which is less than the standard 20% coinsurance for radiation therapy services because you met your maximum out-of-pocket. Radiation therapy services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan says that a previous claim reprocessed to lower your out-of-pocket cost by $317.63. Therefore, this claim processed to apply $317.63 to meet your maximum out-of-pocket.
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 coinsurance for radiation therapy services provided from December 4, 2020, through December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital observation care provided on
September 19, 2020.
You asked the Plan to pay for the initial hospital observation care. The Plan denied your request. The Plan says medical records were not received to confirm or deny the admitting/treating physician, and the date of observation admission.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the initial hospital observation care have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital observation care provided on September 19, 2020.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different 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 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you 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: 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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different 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 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you 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 waive the co-payment for the specialist office visit provided on November 23, 2020.

You asked the Plan to waive the co-payment for the specialist office visit. You say that you should not have any co-payments for the office visits. The Plan denied your request. The Plan says you were charged the co-payment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 co-payment for Physician Services Specialist's Office.

You have been asked to pay a $20 co-payment for the specialist office visit. The specialist office visit falls within the Physician Services Specialist's Office 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 co-payment for the specialist office visit provided on November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for electrodes, per pair (A4556) replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient (A4630) lead wires, per pair (A4557) provided January 18, 2021.
You asked the Plan to pay for the TENS supplies. You say that the tens you ordered really helps you. You had one and it stopped working. After you received this one, you were so happy because it helps so much. You do not like to use pain medications all the time. The Plan denied your request. The Plan says this service is included in another service provided at the same time by the same provider.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this and Medicare rules. CPT codes A4556 and A4630 denied because they are included in the monthly allowance for the TENS unit billed by the same provider for the same date of service. CPT code A4557 denied because a TENS unit has been purchased in the previous 12 months billed by the same provider. Replacement of lead wires more often than every 12 months would rarely be reasonable and necessary. Records were not submitted supporting the necessity for the replacement supplies. Based on this information, we decided that Medicare rules for coverage of the TENS supplies have not been met. Therefore, we decided that the Plan does not have to pay for electrodes, per pair (A4556) replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient (A4630) lead wires, per pair (A4557) provided January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 1, 2021.

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 February 1, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.

You asked the Plan to pre-approve Zilretta. You say that this request is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Zilretta. Our reviewer says that step therapy criteria have not been met in this case. Our physician reviewer found that the review indicates that the enrollee is a 79-year-old male with a history of diabetes and osteoarthritis of the right knee. His provider has requested Zilretta 32 mg every 120 days. The Plan requires a trial of Kenalog before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.