Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON services. You say that the enrollee needs surgery. The Plan denied your request. The Plan says there are in-network providers available within a reasonable distance.

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 inpatient hospital services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on September 3, 2021.
You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says you must use the Plan's
network provider.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services when you use the Plan's network provider.
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not purchased from the
Plan's network provider.
Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met.
Therefore, we decided that the Plan does not have to pay for eyeglasses provided on September 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the coverage criteria have not been 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. In this case, there are no medical records to show that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, requires frequent self-adjustment of insulin dosage based on the blood glucose testing results, or has had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for occupational therapy provided from
June 24, 2021, through July 21, 2021.

You asked the Plan to waive the copayment for occupational therapy. The Plan denied your request. The Plan says there is a $55 copayment for out-of-network occupational therapy visits.

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 $55 copayment for Occupational Therapy visits out-of-network. 

You have been asked to pay $55 copayment for occupational therapy. Occupational therapy falls within the Outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for occupational therapy provided from June 24, 2021, through July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry special stains rendered on October 23, 2020.

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 not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that immunohistochemistry is covered when specific criteria are met.

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee underwent an upper endoscopy on October 23, 2020 for evaluation of abdominal pain with no evidence of intestinal metaplasia, dysplasia or malignancy. The Medicare rules state that a pathologist must first review the routine stain prior to ordering special stains and must provide documentation as to why the special stain is needed. The documentation does not contain this information; therefore, the testing was 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the immunohistochemistry special stains rendered on October 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.

You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you have reached reasonable expectations for improvement.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. The file shows that continued inpatient services from February 4, 2022, were requested. 

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 continued services. Our physician reviewer found that active treatment was not taking place. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question.

The records were supervised and evaluated by a physician. Based upon review the records, you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established
patient (D0150) and intraoral - complete series of radiographic images (D0210) provided September 10, 2021.
You asked the Plan to pay for the comprehensive oral exam and complete series of intraoral x-rays. You say
that the provider knew you were on a limited income, and you don't feel you should have to pay for these
services. The Plan denied your request. The Plan says you have exceeded the frequency limit for these 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. The Plan covers one
comprehensive oral exam every three years and one complete series or panoramic x-ray every five years.
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral
exam and panoramic x-ray were covered on September 20, 2021. Based on this information, we decided that
the Plan's frequency limit for coverage of the comprehensive oral exam and complete series of intraoral x-rays
has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral
evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210)
provided September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee brace (L1851) and suspension sleeve (L2397), provided on September 14, 2021.
You asked the Plan to pay for the knee brace and suspension sleeve. You say that the items should be covered. The Plan denied your request. The Plan says the member obtained this item through unconsolidated phone calls.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the knee brace and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee brace (L1851) and suspension sleeve (L2397), provided on September 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Novolog.
You asked the Plan to pre-approve a tier exception. The Plan denied your request. The Plan says tier exceptions
are not available for drugs covered by Part B.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a 20% coinsurance for Medicare Part B prescription drugs.
We looked at the file and the rules. There is a 20% coinsurance for Medicare Part B drugs. The medication falls
within the Medicare Part B prescription drugs benefit category. This cost sharing is a contractual obligation the
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to preapprove
a tier exception for Novolog.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that your participating provider requested these services. The Plan denied your request. The Plan says the claim has been processed correctly per your 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). Your contract with the Plan clearly says that you must pay 30% coinsurance for outpatient laboratory tests up to a maximum of $3,000. 

You have been asked to pay for the laboratory services. While these services are typically covered, the documentation shows that you had reached your out-of-network/point of service (POS) maximum of $3,000 before you received these services. This means you are liable for the charges received for these services as your benefit was exhausted. This means that you have been asked to pay the correct amount based on your contract
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 22, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from June 9, 2019, to
July 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.
The Plan must follow Medicare rules. Medicare rules say that as a basis for Medicare payment, the following conditions must be met: (6) The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. In this case, an itemized bill was requested by the Plan and was not submitted by the Provider. As such, sufficient information was not provided to determine the amount of payment due. 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 the inpatient services provided from June 9, 2019, to July 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on October 7, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 testing provided on October 7, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on September 23, 2021.

You asked the Plan to pay for the dental service. You say that you were trying to get established with a new dentist. You also say that you would like an exception to be made. The Plan denied your request. The Plan says 1 panoramic x-ray or complete series x-ray is covered every 3 years. The Plan also says that the frequency limit has been exceeded.

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 and the service is listed as covered, the frequency limit has been exceeded.

The record shows that the Plan paid for a complete series x-ray that you received on December 21, 2018. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on September 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided June 16, 2021.

You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because the services provided were medically necessary. The Plan denied your request. The Plan says service is not supported without required information.

The Plan must follow Medicare rules. The rules say that if the patient consents, you must attempt to consult their attending or primary care physician about provided services and either document consent or declination date to consultations and date of consultations in patient's medical record.

We looked at the file and Medicare rules. The submitted claim does not include a referring provider for the services at issue. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on October 15, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also decided that these services are 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 an office visit (99213) provided on October 15, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (D4261) provided on June 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the osseous surgery. You say that you have used this provider before. You also say that you thought you had insurance to cover these services. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that OON providers are allowed to balance bill you for the difference between their billed amount and the Plan's paid amount.

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, you are responsible for the difference between the billed amount and allowed amount because this service was received OON. Therefore, we decided that the Plan does not have to pay for the osseous surgery (D4261) provided on June 21, 2021 by an out-of-network (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 you were told due your complex medical history that you would benefit best from an IRF to get you up and moving as well and quickly as possible. The Plan denied your request. The Plan says your records show that you do not require supervision of a rehabilitation doctor at least three (3) times per week and you do not require aggressive therapies by an intensive team in order to properly regain your function. 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 and a Coronavirus (COVID-19) infection. 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Hereditary Cardiovascular Risk panel provided on September 11, 2020, billed with codes 81401, 81403, 81404, 81405, 81406, 81185, and 81479.

You asked the Plan to pay for the Comprehensive Hereditary Cardiovascular Risk panel. You say that this testing is medically necessary. The Plan denied your request. The Plan says this is considered screening testing, and Medicare denies coverage for all cardiovascular risk assessment testing genomic screening panels for suspected or documented cardiovascular disease.

The Plan must follow Medicare rules. Medicare rules say that genetic testing for cardiovascular disease may only be covered when the 3 criteria listed in the Medicare rules section are met. It is noted that there are no genes which currently are able to meet all these criteria. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Comprehensive Hereditary Cardiovascular Risk panel have not been met. Therefore, we decided that the Plan does not have to pay for the Comprehensive Hereditary Cardiovascular Risk panel provided on September 11, 2020, billed with codes 81401, 81403, 81404, 81405, 81406, 81185, and 81479.