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

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 20, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says if the laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Medicare non-coverage applies to both contracted and non-contracted providers and cannot be overridden by plan directed care. The review has determined that the laboratory services provided to the enrollee on December 20, 2020 were not medically reasonable or necessary. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 20, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a urinary tract infection and has been discharged home to his assisted living facility. The enrollee's medical conditions 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 patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewing radiographic images (D0274), and a teeth cleaning (D1110) provided on January 25, 2021.

You asked the Plan to pay for a periodic oral evaluation, bitewing radiographic images, and a teeth cleaning. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says you are not covered for this service when seen by an out-of-network provider.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, bitewing radiographic images, and a teeth cleaning have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted 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 a periodic oral evaluation (D0120), bitewing radiographic images (D0274), and a teeth cleaning (D1110) provided on January 25, 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 for the enrollee for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's care needs may be met in the skilled nursing facility setting or at home.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of diabetes, neuropathy, stroke, dementia, peripheral vascular disease and tremors who is living at home with falls and weakness despite home health physical therapy. The enrollee's medical conditions 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 patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80048, 80061, 83036, 84450, 84460, 86803) provided to the enrollee on October 5, 2020, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that the services are medically necessary. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 the laboratory services (CPT code(s): 80048, 80061, 83036, 84450, 84460, 86803) provided to the enrollee on October 5, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories for a prosthesis (L5637, L5910, L5988) for the enrollee.

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the requested socket accessories are not reasonable and necessary for the approved preparatory prosthesis.

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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found besides the prosthetist's statement, there are no corroborating medical records provided documenting the need for theses accessories.

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories for a prosthesis (L5637, L5910, L5988) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a positron emission tomography (PET) scan with computed tomography (CT) full body (78816) and fluorodeoxyglucose (A9552) provided on February 24, 2021.
You asked the Plan to waive the copayment for a PET scan. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $300 copayment for outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $300 copayment for a PET scan. The EOC confirms $300 is the required copayment for this service. A PET scan 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 a positron emission tomography (PET) scan with computed tomography (CT) full body (78816) and fluorodeoxyglucose (A9552) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing evaluation services (96132).

You asked the Plan to pre-approve neuropsychological testing evaluation services. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested services are not medically necessary and reasonable.

The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain. 

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 neuropsychological testing evaluation services. Our reviewer says that the requested procedure is not medically reasonable and necessary.

Our physician reviewer found that based on review of the records provided, this patient does not meet the criteria for neuropsychological testing. In this case, the documentation shows his memory difficulties as patient complaints with no clear examination of his memory issues. Documentation shows the desire for neuropsychological testing; however, there is no explanation as to what is being tested. It is therefore not medically necessary or reasonable to have neuropsychological testing as outlined for this patient does not have quantification of his memory difficulty.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuropsychological testing evaluation services have not been met. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing evaluation services (96132).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99215) provided on December 3, 2020 by an out of network (OON) provider.

You asked the Plan to pay for an OON office visit. You say that the provider was not aware they were not in-network. The Plan denied your request. The Plan says this was 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 an office visit (99215) provided on December 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist services rendered from January 4, 2021 to March 1, 2021.

You asked the Plan to waive the copayments for these services. You say that you didn't know the provider opted out of Medicare. The Plan denied your request. The Plan says the copayments were 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 $35 copayment for physician specialist services.

Review of the file shows that you received specialist services on January 4, 2021 and March 1, 2021. You have been asked to pay a $35 copayment per date of service for these services, for a total of $70. These services fall within the physician specialist 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 copayments for the specialist services rendered from January 4, 2021 to March 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an MRI scan of the lumbar spine (72148) provided on March 1, 2021.

You asked the Plan to waive the deductible for an MRI scan of the lumbar spine. You say that you were told by the provider that you would not be billed because you were not provided with the proper testing. The Plan denied your request. The Plan says the correct cost-sharing was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for outpatient radiological diagnostic services, not including X-rays, excluding diagnostic mammograms. 

The item or service you asked the Plan to waive the deductible for falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for outpatient radiological diagnostic services, not including X-rays, excluding diagnostic mammograms. This cost sharing is a contractual obligation that had not been met at the time an MRI scan of the lumbar spine was received on March 1, 2021. Therefore, we decided  that the Plan does not have to waive the deductible for an MRI scan of the lumbar spine (72148) provided on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lymphedema surgery.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says cosmetic surgery is not a covered benefit.

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 requested services. Our physician reviewer found that you underwent (vibration amplification of sound energy at resonance) VASER liposuction for lipedema on both legs by a plastic surgeon. Repeat liposuction for lipedema was recommended. You have tried compression stockings and are undergoing physical therapy. You have not yet completed these at the time of this request. The requested service is indicated for your condition. However, as this appears to be more of a cosmetic procedure, it is not medically necessary. 

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve lymphedema surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (CPT code G0483) provided to the enrollee on November 6, 2020.

You asked the Plan to pay for the drug test. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 the drug test (CPT code G0483) provided to the enrollee on November 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray of the chest (71046) provided on March 3, 2021.

You asked the Plan to waive the copayment for an x-ray of the chest. You say that the health department mandated a chest x-ray, and you should not be responsible for a copayment. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 and therapeutic services and supplies including x-rays.

You have been asked to pay a $73.57 copayment for an x-ray of the chest. The EOC confirms $110 is the required copayment for this service. You have been asked to pay a copayment of $73.57, which is less than the Plan's contracted amount. An x-ray of the chest 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 an x-ray of the chest (71046) provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services you received on March 18, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you have been asked to pay the correct amount.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The refraction you asked the Plan to pay for is considered a routine vision service and is not covered when provided during a Medicare-covered eye exam. Additionally, there is a $30 copayment for Medicare-covered vision services. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the vision services you received on March 18, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve new routine eyeglasses.

You asked the Plan to pre-approve eyeglasses. You say that the new eyeglasses are medically necessary. The Plan denied your request. The Plan says eyeglasses have already been covered in the past year and you are not eligible for a new pair of eyeglasses until July 17, 2021.

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 once a year. 

We looked at the file and the Plan's rules. In this case the Plan provided documentation that routine eyeglasses were covered on July 17, 2020. Thus, the enrollee was not yet eligible for new eyeglasses at the time of the appeal. Therefore, we decided that the Plan does not have to pre-approve new routine eyeglasses. If the enrollee still requires new eyeglasses, you may wish to submit a new request for coverage for eyeglasses to be purchased at a later date.