Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) receiver and supply
allowance.
You asked the Plan to pre-approve the CGM receiver and supply allowance. You say that you need a less
painful way to test your glucose blood levels. The Plan denied your request. The Plan says the criteria for
coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
the CGM receiver and supply allowance have not been met. Therefore, we decided that the Plan does not have
to pre-approve continuous glucose monitor (CGM) receiver and supply allowance.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance cholangiopancreatography (MRCP).
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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a pancreatic cyst. A prior MRCP was performed in September of 2021 and you had an abdominal computed tomography (CT) scan on June of 2021 that showed no progressive growth over this time period. The repeat MRCP to monitor the pancreatic cyst is not reasonable or medically necessary due to no growth or change to justify repeat imaging. 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 magnetic resonance cholangiopancreatography (MRCP).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmologist office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an ophthalmologist office visit. You say that you saw this provider in the past and would like to continue. The Plan denied your request. The Plan says this is available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pre-approve an ophthalmologist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve office services. You say that you need this treatments for your condition, and it will take you 6-8 months to see a rheumatology provider in your area. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDX-SCC test provided to the enrollee on June 7, 2021.
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this panel has not met the MolDX process for clinical validity and utility.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a shave biopsy of skin lesions on March 12, 2021 which showed well differentiated squamous cell cancer of the skin on the left forearm and right lower leg. There is no documentation of deep or perineural invasion. The lesions measured less than 2 centimeters in greatest dimension to guide monitoring and treatment. There is no documentation of advanced, relapsed, or recurrent cancer, or spread to other areas of the body (metastases). There is no documentation of a personal history of other cancers. There is no documentation of current ongoing cancer treatment or the plan to seek further cancer treatment. Further, this panel has not met the MolDX process for clinical validity and utility. In addition, this testing is not a Medicare covered screening service. The review has determined that the enrollee does not meet the criteria for this testing. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDX-SCC test provided to the enrollee on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), preventive procedures (D1999), amalgam (D2150), anterior resin-based composite of one surface (D2330), posterior resin-based composite of one surface (D2391), posterior resin-based composite of two surfaces (D2392), and periodontal scaling and root planing (D4342) provided from July 28, 2020, to August 11, 2020.
You asked the Plan to pay for the dental services. You say that your dentist verified that each of these procedures was solely necessary. You also say that your policy does cover these dental services because they were required to treat illness and it was performed as outpatient care, as the insurance policy states. The Plan denied your request. The Plan says these services are not covered by Medicare. The Plan also says that you do not have a supplemental benefit for the provided dental services.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), preventive procedures (D1999), amalgam (D2150), anterior resin-based composite of one surface (D2330), posterior resin-based composite of one surface (D2391), posterior resin-based composite of two surfaces (D2392), and periodontal scaling and root planing (D4342) provided from July 28, 2020, to August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 1, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you switched primary care physicians. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 office visit provided on July 1, 2021, by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on May 9, 2021.
You asked the Plan to waive the copayment for an MRI. You say that you never saw the physician and only received an MRI. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $110 copayment for MRI's. You have been asked to pay the allowed amount of $106.72, which is less than the $110 copayment for an MRI. An MRI 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 MRI provided on May 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the clinical information provided supports the need
for care in an IRF. The Plan denied your request. The Plan says the enrollee does not need to be seen by a
rehabilitation doctor at least 3 times a week for evaluation of functional and medical goals and progress. the
enrollee does not need an intensive team for her care. The Plan says that the enrollee can safely receive the care
needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for surgical repair of a distal femur fracture after a fall. The enrollee's medical problems are
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. While the documentation does support a need for physical and/or occupational therapy, there
is no documented need for a intensive, multi-disciplinary rehabilitation program. 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.
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 reduce the copayment for the specialist office visits provided on January 8, 2021, and February 19, 2021.

You asked the Plan to reduce the copayment for specialist office visits. You say that this was a general office visit and should be charged a $10 copayment for the visits. The Plan denied your request. The Plan says you have been asked to pay 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 specialist doctor visit for Medicare-covered services. 

You have been asked to pay a $50 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/practitioner services, including doctor's office visits" benefit category. The record shows the provider is a rheumatologist who is considered a specialist. 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 reduce the copayment for the specialist office visits provided on January 8, 2021, and February 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for knee replacement surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on February 11, 2021.
You asked the Plan to pay for the eye refraction. You say that you do not understand why these services are denied for payment and are frustrated with the information provided by the Plan. You also say that you spoke to the provider's office and they cannot find or see a bill for the enrollee, and you do not know what happened to it. The Plan denied your request. The Plan says eye refractions are not covered by Medicare. The Plan offers a supplemental benefit that can cover refractions as part of a routine eye exam to evaluate the need for glasses or contacts, but these services must be received from a provider in the Plan's routine vision network. The provider in question is not part of this network, so the eye refraction is denied for payment.
Medicare generally does not cover routine vision and eyewear services, including refractions. 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 eye refractions when they are received as part of a routine eye exam from a provider in the Plan's specified routine vision network. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's routine vision network. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on February 11, 2021.
Please note: we have read your letter and understand you may also have some confusion regarding the status of the bill, as the provider was unable to locate a balance for this date. The Plan has indicated that they have agreed to pay for the eye exam provided on February 11, 2021, which was billed in the amount of $160. The claim receipt shows no cost-sharing for this service. In addition, you indicated in your appeal that the enrollee paid $25 for the eye refraction at the time of service. You may verify this information with the providers office, but if that is the case then the enrollee may not owe an additional amount for the service, but is not entitled to reimbursement from the Plan for the eye refraction.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips.
You asked the Plan to pre-approve additional transportation trips. You say that it is hard to get around and management is not being mindful of your pains. You say that you are not able to ride the bus and are requesting 10 additional rides. The Plan denied your request. The Plan says any trips beyond the 96 approved are not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 96 routine transportation trips per calendar year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for additional coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional transportation trips.
Your complaint about being a prisoner in your home 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the
enrollee has not had two injections of numbing medicine.
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under
certain medical indications.
We looked at the file and Medicare rules. The records show that the enrollee received one medial branch block,
which provided only 4-6 hours of pain relief. The rules say that the enrollee needs 2 medial branch blocks with
sustained pain relief before radiofrequency ablation will be considered.
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 radiofrequency ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound study provided on June 4, 2021.
You asked the Plan to waive the copayment for an ultrasound study. You say that the original test was inaccurate and you were never informed of the charges ahead of time. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $125 copayment for ultrasounds. You have been asked to pay a $125 copayment for an ultrasound study. An ultrasound study 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 ultrasound study provided on June 4, 2021.
We note your complaint that the test was inaccurate. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Sincerely,