Persius/hicric huggingface dataset:
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the deluxe frames (V2020) spherocylinder, trifocal lenses (V2303) anti-reflective coating, per lens (V2750).

You asked the Plan to pay for the eyeglasses. You say that you have not used the $150 allowance for a couple of years and was assured by the Plan's eyeglasses provider that it was available to you. You believe this denial is in error. The Plan denied your request. The Plan says the total cost was $892.40. The $150 benefit was applied to the purchase therefore, the balance correctly applied as your responsibility.

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 $150 eyewear allowance once every 24 months for Vision care.

You have been asked to pay $742.40 for the eyeglasses. The eyeglasses fall within the Vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the deluxe frames (V2020) spherocylinder, trifocal lenses (V2303) anti-reflective coating, per lens (V2750).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a pelvic fracture after a fall. Her medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record documents a need for physical and occupational therapy but not for an intensive rehabilitation program. Medically necessary services could be provided at a low level of care. Additionally, there is a not reasonable expectation that this patient will be able to fully participate in and benefit from an intensive rehabilitation therapy program provided in an IRF. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology, gross and microscopic examination
(88305) immunohistochemistry or immunocytochemistry, per specimen (88342) provided by an OON provider.

You asked the Plan to pay for the pathology services. You say that you moved to Maryland and did not
realize the Plan would not cover these services and more. The Plan denied your request. The Plan says
enrollee's must receive their medical services from an in-network provider with the exception being urgent or
emergent services. Non-emergent services with non-contracted providers require prior authorization before
services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for surgical pathology, gross and microscopic
examination (88305) immunohistochemistry or immunocytochemistry, per specimen (88342) provided
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedures (97112 and 97530).

You asked the Plan to pay for the therapeutic procedures. You say that you would like reconsideration because you have a referral for chiropractic services. The Plan denied your request. The Plan says the requested services are not a Medicare covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for therapeutic procedures (97112 and 97530).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. You say that you are the only provider for the testing services. The Plan denied your request. The Plan says the services require 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 provider in this case is not a network provider with the Plan. 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 lab services provided on May 6, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says care needs can be safely addressed through the use of non-skilled personnel.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammogram (77063, 77067) provided by an out of network (OON) provider.

You asked the Plan to pay for the mammogram. You say that you did not know your services would not be covered when you moved. The Plan denied your request. The Plan says the services do not meet criteria for OON coverage.

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 screening mammogram (77063, 77067) provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycodone Hydrochloride (J8499), 30 mg tablet.

You asked the Plan to pre-approve Oxycodone HCl. You say that the enrollee is able to perform activities of
daily living. The Plan denied your request. The Plan says the requested drug is considered self-administered.
The Plan also says that self-administered drugs are not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Oxycodone Hydrochloride
(J8499), 30 mg tablet.

Benefits for Oxycodone HCl 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a lower extremity study (93925).

You asked the Plan to waive the copayment for a lower extremity study. You say that you want the plan to pay
for the services. The Plan denied your request. The Plan says the copayment was 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 a $45
copayment for advanced imaging.

You have been asked to pay a $45 copayment for a lower extremity study. The service at issue falls within the
advanced imaging 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 lower extremity
study (93925).

Your complaint about not being satisfied with the services 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CT scan of the abdomen (74170).

You asked the Plan to pre-approve the CT scan. You say that you would like reconsideration because this CT
scan is needed to complete staging. The Plan denied your request. The Plan says a similar study has already
been authorized and its results nay obviate the need for additional imaging.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically 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 the CT scan. Our reviewer says that the
CT of the abdomen is duplicative. Our physician reviewer found the results of the prior PET CT do not show
metastasis in the abdomen.

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 CT scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve the CT scan of the abdomen (74170).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for pyelonephritis. Her medical problems are stable. There are no complex nursing or rehabilitation needs.

The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record documents a need for physical and occupational therapy but not for an intensive rehabilitation program. Medically necessary services could be provided at a low level of care.

Additionally, there is a not reasonable expectation that this patient will be able to fully participate in and benefit from an intensive rehabilitation therapy program provided in an IRF.

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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the lumbar-sacral orthosis was medically
necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence the provider ever
saw the member.

The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is covered when it is ordered for a
Medicare-approved indication.

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 the lumbar-sacral orthosis. Our reviewer
says that the requested lumbar-sacral orthosis was not medically reasonable and necessary for the enrollee in
this case. Our physician reviewer found an appropriate history and a physical examination of the back would
reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have
been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more
of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a
credible physical examination of the back.

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the
Plan does not have to pay for the lumbar-sacral orthosis (L0650).
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 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 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. The medical record documents a need for physical and occupational therapy but not for an intensive rehabilitation program. Medically necessary services could be provided in a low level of care. There is a not reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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 the medical services (99326, G0180, 99490, G2058, 99335, G0439, G8752, G8754, 1170F, 1125F 3288F, G8510, 9949l, G0179) provided by an out of network (OON) provider.

You asked the Plan to pay for OON services. You say that these services should be covered. The Plan denied your request. The Plan says these 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 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 (99326, G0180, 99490, G2058, 99335, G0439, G8752, G8754, 1170F, 1125F 3288F, G8510, 9949l, G0179) provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) of the neck.
You asked the Plan to pre-approve the MRA of the neck. You say that the requested test would help diagnose
the enrollee's conditions and is supported by the records provided. The Plan denied your request. The Plan says
the requested MRA of the neck is not medically necessary.
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 MRA of the neck. Our reviewer
says that the MRA of the neck is not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee's provider ordered this testing based on DWI associated ischemic changes seen on
a prior MRI of the brain. The provider was suspicious of possible prior emboli. However, the enrollee was not
noted to have an acute stroke, vascular occlusion or thrombosis. Nor had the enrollee undergone any prior
diagnostic work-up for the vasculature of their neck to suggest significant stenosis or a similar finding for
which advanced imaging would be necessary. In this situation, it cannot be said that the criteria for coverage of
this service have otherwise been 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 the MRA of the neck have not been met. Therefore, we decided that the Plan
does not have to pre-approve magnetic resonance angiography (MRA) of the neck.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a
participating provider on November 15, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you were very sick, and you
were later diagnosed with Covid-19. You say that you do not think that you should have to pay for this. The
Plan denied your request. The Plan says the correct copayment has 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 $240
copayment for ambulance services.
You have been asked to pay a $240 copayment for ambulance services. Ambulance services falls within the
ambulance services 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 ambulance services
provided by a participating provider on November 15, 2020.