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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary. 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 nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for sepsis, encephalopathy, and atrial flutter. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medicare coverage criteria are not met. 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 for the enrollee.
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 IRF care is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of stroke with hemiparesis and is living at home receiving home health services. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or therapy needs. The documentation does not show a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medicare coverage criteria are not met. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion spacer for the enrollee.

You asked the Plan to pre-approve the Vertiflex Superion spacer. You say that the Vertiflex Superion spacer is medically necessary. The Plan denied your request. The Plan says the Vertiflex Superion spacer is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the Vertiflex Superion spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex Superion spacer is considered experimental and is not covered by Medicare. 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 Vertiflex Superion spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion spacer for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the dispute was not filed in a timely manner.

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 looked at the file and the rules. The claim provided shows that the services were billed with a place of service code of 81. The records do not indicate the enrollee's sample was taken in an independent laboratory. 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 pathology services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit.

You asked the Plan to waive the copayment for the emergency room visit. You say that you did not know you would be charged a copayment to have your stitches removed. You say you thought it would be considered a follow-up visit. 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 $90 copayment for each Medicare-covered emergency room visit.

You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.

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 emergency room visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision examination.

You asked the Plan to pay for the vision examination. You say that this was a routine vision exam with no copayment. The Plan denied your request. The Plan says this was a diagnostic eye examination and is not covered under your Vision Care benefit.

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 routine vision exams including dilation and refraction as necessary.

We looked at the file and the Plan's rules. The provider submitted the claims as a diagnostic vision exam. Based on this information, we decided that the Plan's rules for coverage of the vision examination have not been met. Therefore, we decided that the Plan does not have to pay for the vision examination.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray services (Q0092, R0070).

You asked the Plan to pay for portable x-ray services. You say that this was billed correctly. The Plan denied your request. The Plan says this was billed with an incorrect POS.

The Plan follows Medicare rules. Medicare rules say that POS code 32 should be used with services for beneficiaries in a noncovered SNF stay.

We looked at file and Medicare rules. The record shows that the services at issue were provided during a non-covered SNF stay, but were billed with POS 31. Based on this information, we decided that Medicare rules for coverage of portable x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for portable x-ray services (Q0092, R0070).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for incision and drainage of abscess during the emergency department visit.

You asked the Plan to pay for incision and drainage of abscess (10061). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the medical records do not support the complexity of the billed 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.

In this case, the CPT Code Manual definition of code 10061 is Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple.

We find that CPT code 10061 is not supported in the medical record. Specifically, the medical notes say incision and drainage was not required. Based on this information, we decided that Medicare rules for coverage of incision and drainage of abscess (10061) have not been met. Therefore, we decided that the Plan does not have to pay for incision and drainage of abscess during the emergency department visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there were network providers available in the area.

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 file shows that you received routine vision care from an out-of-network provider. We looked at the file and the Plan's rules. Your Plan only covers care with a doctor in the vision network. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cataract surgeries, the eye exam, or the specialist office visit provided from October 6, 2020, to October 14, 2020.

You asked the Plan to waive the copayments for the cataract surgeries, the specialist office visit or the eye exam. You say that you should not be responsible for the surgery copayments or the $40 copayment for post-op care. 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 $250 copayment per visit for in-network Medicare-covered ambulatory surgical center and outpatient hospital facility visit, a $40 copayment for each in-network specialist visit for Medicare-covered benefits and a $30 copayment per visit for in-network exams to diagnose and treat diseases and conditions of the eye.

You have been asked to pay a total of $360 for the cataract surgeries, the specialist office visit, and the eye exam. The cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The eye exam falls within the "Vision care" benefit category. See chart below.

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 cataract surgeries, the eye exam, or the specialist office visit provided from October 6, 2020, to October 14, 2020.

Your complaint about how the doctor performed surgery 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the back brace provided on August 11, 2020.

You asked the Plan to waive the coinsurance for the back brace. You say that you and the insurance company are paying too much for this back brace. 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 20% coinsurance for in-network Medicare-covered equipment and supplies. 

You have been asked to pay $259.57 which is 20% of the allowed amount for the back brace. The allowed amount is $1,297.87. ($1,297.87 x 20% = $259.57). The back brace falls within the "Durable medical equipment (DME) and related supplies" 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 coinsurance for the back brace provided on August 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray.

You asked the Plan to waive the copayment for the x-ray. 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 each Medicare-covered x-ray in an in-network outpatient hospital facility.

You have been asked to pay a $50 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 x-ray.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided an out-of-network provider.

You asked the Plan to pay for the home visit. You say that the physician provided medically necessary services. You say the doctor should not be penalized for the hospital's staff failure to obtain authorization for the service. The Plan denied your request. The Plan says this service was done by an out-of-network provider and the service was not urgent or emergent nor approved in advance.

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 a home visit provided an out-of-network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for COVID-19 testing (C9803, U0003).

You asked the Plan to pay for the COVID-19 testing. You say that the service was medically necessary and should be covered. The Plan denied your request. The Plan says that COVID testing solely for reasons of pandemic control or re-opening the economy is not covered.

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's directive included in the case file, titled "Advocacy Review of COVID-19 Antibody & Viral Testing Grievances" states that testing that is performed solely for reasons of pandemic control or re-opening the economy is not covered and the member will be held liable, EXCEPT for Medicare Advantage, Medicare Managed Care, and Health and Recovery Plans. It further states that Medicare or Medicaid members should never have member liability.

The Member is enrolled in a Medicare advantage plan. Based on the Plan's cited policy, the member is not held liable for the COVID-19 testing. Therefore, we decided that the Plan has to pay for COVID-19 testing (C9803, U0003).

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy services provided by an out of network provider.

You asked the Plan to pay for chemotherapy services. You say that the enrollee was ordered to receive outpatient services by a licensed and qualified physician. The Plan denied your request. The Plan says you did not request prior authorization.

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 chemotherapy services provided by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because these services are medically necessary. The Plan denied your request. The Plan says this testing was not billed correctly.

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 laboratory services, was requested solely for screening purposes. The documentation does not show that the requested pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-making regarding the need for the use of any specific drug. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus Gene Panel testing.

You asked the Plan to pay for the services provided. You say that the testing is a valuable tool when determining treatment for the enrollee. The Plan denied your request. The Plan says a panel constitutes a single procedural service.

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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. 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 Tempus Gene Panel testing.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.

You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when four factors 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 skilled nursing facility services. Our physician reviewer found based on the medical records, as of February 27, 2021 you did not require any skilled nursing or therapy services on a daily basis. You did not require further skilled therapy to establish a safe and effective maintenance program. As of February 27, 2021, your function was at or near your prior level of function and any further care would be custodial. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility services. have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tooth regeneration (D4266), bone replacement graft for ridge preservation (D7953), and therapeutic parental drugs (D9612).

You asked the Plan to pay for the guided tooth regeneration, bone replacement graft, and therapeutic parental drugs. You say that you would like these services to be covered by the Plan. The Plan denied your request. The Plan says these procedures are not covered under your benefit plan.

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 guided tooth regeneration (D4266), bone replacement graft for ridge preservation (D7953), and therapeutic parental drugs (D9612).