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

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that you could and should benefit from inpatient rehabilitation. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to be functioning at/near your baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services provided on April 5, 2021.
You asked the Plan to pay for the services provided. You say that a prescription was required to update your eyeglasses. The Plan denied your request. The Plan says eye refractions are only covered as a routine service.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The file shows you received an eye exam for age-related cataracts. You also received refraction services. We looked at the file and the Plan's rules. Refraction services are only covered during a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on August 25, 2020.
You asked the Plan to pay for laboratory services. You say that this testing was performed for clinical purposes. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for anticoagulation services you received at your cardiologist's office on June 22, 2021.
You asked the Plan to waive the copayment for the anticoagulation management services. You say that you do not pay for labs, and you are being charged for a visit even though you didn't see the doctor. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for medical services in a specialist's office. You have been asked to pay a $40 copayment for the anticoagulation management services. Records show that this included not only lab testing, but an evaluation with the nurse in the cardiologist's office.
The nurse reviewed your diet, medications, current status, and lifestyle changes. These are part of a practitioner service in a specialist's office- these are not part of a lab service. That is why the specialist services copayment applies. This copayment applies to any services received in a specialist's office, regardless of whether you see the doctor or not. 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 anticoagulation services you received at your cardiologist's office on June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and deductible for a diagnostic mammogram
(77066) and digital breast tomosynthesis (G0279) provided on June 24, 2021.
You asked the Plan to waive the copayment and deductible for a diagnostic mammogram. You say that you
were asked to request a referral for a diagnostic mammogram due to the presence of tenderness in your right
breast. You do not believe you should have to pay for this service because it was no different from other
mammograms you have received in the past which were covered in full. The Plan denied your request. The
Plan says the cost-share 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 $10
copayment per day, per provider, after the $300 deductible is met for Outpatient Diagnostic Tests and
Therapeutic Services and Supplies.
You have been asked to pay a cost-share of $142.16 for a diagnostic mammogram. According to the Plan's
Explanation of Benefits (EOB), your deductible had not been met at the time of this claim. Thus, the allowed
amount of $142.16 is applied to your deductible. 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 and
deductible for a diagnostic mammogram (77066) and digital breast tomosynthesis (G0279) provided on June
24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99215) electrocardiogram, with interpretation and report (93000) transthoracic echocardiography (93306) duplex scan (93880) complete bilateral noninvasive physiologic studies of upper or lower extremity arteries (93923) provided February 9, 2021 to March 20, 2021.
You asked the Plan to waive the copayment for the outpatient diagnostic services. You say that you were unaware that the Plan did not pay the entire amount for these exams and if you would have known you would not have done them in the first place. The Plan denied your request. The Plan says the claims were processed with the correct copayments applied per the Evidence of Coverage.
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 $30 copayment for Medicare covered non-radiological diagnostic services, $155 copayment for each Medicare covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free standing facility and $25 copayment for services obtained from a specialist. You have been asked to pay $381.93 ($25 + $16.93 + $155 + $155 + $30) for the outpatient diagnostic services. The outpatient diagnostic services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies and Physician/Practitioner Services, Including Doctor's Office Visits 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 outpatient office visit (99215) electrocardiogram, with interpretation and report (93000) transthoracic echocardiography (93306) duplex scan (93880) complete bilateral noninvasive physiologic studies of upper or lower extremity arteries (93923) provided February 9, 2021 to March 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says there are in-network providers available.
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 pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation (A0427, A0425) rendered on December 14, 2020.
You asked the Plan to waive the copayment for ambulance transportation. You say that the services were necessary because you were unable to walk. The Plan denied your request. The Plan says you were charged the correct copayment.
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 $225 copayment for Ambulance Services.
You have been asked to pay a $225 copayment for ambulance transportation. 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 transportation (A0427, A0425) rendered on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve immediate maxillary and mandibular dentures.
You asked the Plan to pre-approve dentures. You say that the dentures you currently have are too big and you cannot eat with them. The Plan denied your request. The Plan says that this benefit is exhausted.
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. The Plan covers one upper and one lower denture every five years. We looked at the file and Medicare rules. The file indicates the Plan covered one upper and one lower denture on December 9, 2020, which is less than five years ago. Based on this information, we decided that the Plan's rules for coverage of dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve immediate maxillary and mandibular dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for eyeglasses provided on June 11, 2021.
You asked the Plan to pay the full amount for eyeglasses. You say that your new eyeglasses do not work, and
you would like a full refund. The Plan denied your request.
The Plan says the routine vision hardware claim processed correctly according to the enrollee's benefits. The
enrollee's vision provider has offered to make necessary changes to the enrollee's eyeglasses to accommodate
her vision needs. As such, the Plan should not be held liable to reimburse the enrollee her out-of-pocket costshare.
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.
We looked at the file and the Plan's rules. The file shows that the Plan processed the routine vision hardware
claim correctly according to your benefit. Therefore, we decided that the Plan does not have to pay the full
amount for eyeglasses provided on June 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your request. The Plan says that you have not tried and failed Stelara.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Entyvio. Our reviewer says that Entyvio is not medically reasonable and necessary. You have Crohn's disease. Your provider has requested medical therapy with Entyvio. The Plan requires a trial of Remicade OR Inflectra; AND Stelara before they will approve the requested drug. In this case, you have not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy criteria for Entyvio. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on March 13,
2021.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says claims for services to beneficiaries for
which Medicare is the secondary payer must be directed first to the primary plan where there is primary
coverage for the services involved.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for the critical care services until the primary insurer has denied the claim for these services. Therefore, we
decided that the Plan does not have to pay for the critical care services (99291) provided on March 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wheelchair ramps provided on May 5, 2021, by an OON
provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without 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 must 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 wheelchair ramps provided on May 5, 2021, by an
OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says your records do not show that you do need to be seen by a rehabilitation doctor
three (3) times a week. The Plan states you do not need an intensive team (rehab doctor and nurse, social
worker, and therapists) for your care. The Plan states you can safely receive the services you need in other
settings, for example: a skilled nursing facility, home with home health and home physical therapy, 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 your nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were
admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex
nursing or rehabilitation needs. You do 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 an intensive,
multi-disciplinary 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.
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 IRF admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) computed tomography (CT) scan from head to thigh.
You asked the Plan to pre-approve a PET/CT scan from head to thigh. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET/CT scan from head to thigh. Our reviewer says that the services are medically necessary. Our physician reviewer found the urologist correctly is concerned about potential metastatic disease since the doubling of prostate-specific antigen (PSA) over a few years is not at all typical for a low-grade prostate cancer. The possibility that the biopsy results are misleading and understating the aggressiveness of the tumor are to be considered in light of the PSA level being atypical for a low-grade prostate cancer. Recent recommendations in the literature advocate the use of Axumin PET/CT in lieu of a battery of conventional imaging tests which are less specific than PET. For these reasons the requested PET/CT should be approved and would be the best single test for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET/CT scan from head to thigh have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) computed tomography (CT) scan from head to thigh.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 82192, 81006, and 81301
provided on February 19, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 82192, 81006 and 81301 are not supported in the medical record. Specifically, if a
laboratory assays two or more genes in an enrollee in parallel, then those two or more genes will be considered
part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the
panel. Review of the file shows that more than one code was submitted for the panel provided. Based on this
information, we decided that Medicare rules for coverage of the laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 82192, 81006, and
81301 provided on February 19, 2021.