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

We decided that the Plan does not have to pay for the infectious agent detection (87998) provided on April 12,
2021.
You asked the Plan to pay for the infectious agent detection. You say that you would like reconsideration
because you performed the testing ordered by the referring physician. The Plan denied your request. The Plan
says screening testing is not a Medicare benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, the infectious agent detection, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted
does not include any clinical information to verify why this this testing was ordered or if it was medically
necessary. Therefore, we decided that the Plan does not have to pay for the infectious agent detection (87998)
provided on April 12, 2021.
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 the stay is not medically necessary.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on May 20, 2021.

You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says eye refractions
are not a covered benefit under your Plan.

Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered
diagnosis or treatment of illness or injury.

We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered
eye condition and not a routine eye exam. Medicare does not cover refractive procedures even when
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided
that the Plan does not have to pay for an eye refraction provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease (CPT code 99072) provided to the enrollee on November 5, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed by the provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the services has a bundled relationship with another and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease (CPT code 99072) provided to the enrollee on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network physician services.
You asked the Plan to pre-approve out-of-network services. You say that you prefer to see the requested
provider. The Plan denied your request. The Plan says there are providers in network who can treat you.
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 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 out-of-network physician
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on August 12, 2020.
You asked the Plan to pay for an eye refraction. You say that this expense has always been covered in the past.
The Plan denied your request. The Plan says services are not covered under your benefit plan unless rendered
by a routine vision provider.
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 when it is performed as a routine screening by a participating
provider.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of an eye refraction have not been met. Specifically, an eye refraction is only covered by the Plan
when it is performed as part of a routine screening by a participating provider. This service was performed for
medical vision purposes, and therefore is not a covered benefit. Based on this information, we decided that the
Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not
have to pay for an eye refraction (92015) provided on August 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six office visits to be rendered by the OON provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render
the requested services.
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 services. Therefore, we decided that the Plan does not have to pre-approve six office
visits to be rendered by the OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant (D6010), implant supported crown (D6065),
prefabricated abutment (D6056), and bone replacement graft (D7953).
You asked the Plan to pre-approve the dental services. You say that you were advised by customer service that
the services were covered. The Plan denied your request. The Plan says implants and related services are not
covered dental services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested implant and related
services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pre-approve an implant (D6010), implant supported crown (D6065), prefabricated abutment (D6056), and bone
replacement graft (D7953).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee is unable to take care of himself. The Plan denied your request. The Plan says that the enrollee could be effectively and safely cared for in a less restrictive setting other than in a locked inpatient psychiatric unit.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. It is not expected this enrollee would improve in a reasonable period of time as he is not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. This patient was compliant with treatment and having no side effects to the medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he does not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you need the compression
stockings and had a prescription for them. The Plan denied your request. The Plan says the requested item is
not covered
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is not safe for discharge and requires continued care at an LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services. With time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve automobile accessories, hand controls (E1399) gas
pedal controls (E1399) brake pedal controls (E1399) and throttle controls (E1399).

You asked the Plan to pre-approve the automobile accessories. You say that you have no transportation to the
doctor's office. Before Coronavirus, you were at the gym for 8 hours a week. The Plan denied your request.
The Plan says these items do not meet the criteria of durable medical equipment, is for exclusive use outside
the home setting and are not primarily used to serve a medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve automobile accessories, hand controls (E1399) gas pedal
controls (E1399) brake pedal controls (E1399) and throttle controls (E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (CPT code(s): 81317, 81404, 81405, 81406, 81407, 81408, 81162, 81435, 81479, 81403, 81308, 81437) provided to the enrollee on March 23, 2021.

You asked the Plan to pay for the genetic testing. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

This request is not a covered benefit because there is no documentation to support the medical necessity for each biomarker performed in this panel or that each biomarker performed is relevant to the enrollee's personal and family history. Although the enrollee had ovarian cancer in the past, these request tests were not ordered nor offered in the context of professional genetic expertise. There is no indication that these biomarkers will be used to assist in the enrollee's management or treatment. These biomarkers are not covered Medicare screening tests. Further these tests were performed as one genomic sequencing procedure as opposed to multiple individual procedures and should be reported as one unit of 81479. The genetic testing was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing (CPT code(s): 81317, 81404, 81405, 81406, 81407, 81408, 81162, 81435, 81479, 81403, 81308, 81437) provided to the enrollee on March 23, 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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the necessary services in a less intensive setting.
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 that 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. 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve skilled nursing facility (SNF) services. You say that you are bedbound and on oxygen, and you cannot take care of yourself, so you need a SNF admission. The Plan denied your request. The Plan says no daily skilled nursing needs are noted.
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 skilled nursing facility (SNF) services.
Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the
medical records provided this patient does require skilled therapy services, i.e., the specialized skill, knowledge
and judgment of a qualified therapist are required to safely and effectively provide medically necessary and
reasonable treatment. Daily skilled services are not required. Therapy 2-5 times per week is recommended in
the available records. This patient does not require the services on an inpatient basis, only 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 skilled nursing facility (SNF) services have not been met. Therefore, we
decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection (CPT code 78452) provided on October 8, 2020, by an in-network provider.
You asked the Plan to waive the copayment for the service. You say that if you knew that it will be so much money in copayment you would not have had the testing done. The Plan denied your request. The Plan says they partially overturn the copayment to reduce copayment from $250 to $45 based on plan benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Review of the file show that you received myocardial perfusion imaging on October 8, 2020, by an in-network provider. You were asked to pay a $45 copayment for the service. Your 2020 EOC states that enrollees must pay a $45 copayment for in-network diagnostic procedures and tests. 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 myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection (CPT code 78452) provided on October 8, 2020, by an in-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto 20MG tablet (CPT code J8499), for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is needed for abnormal heart rhythm/atrial fibrillation (AFIB). The Plan denied your request. The Plan says the requested drug is intended for patient 'self-administration' and is not covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Xarelto 20MG tablet (CPT code J8499), for the enrollee.
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.