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

 We decided that the Plan does not have to pre-approve SNF services.  

You asked the Plan to pre-approve SNF services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the skilled nursing facility services you and/or your provider are requesting do not meet the requirements for approval.  

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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications and insulin. The enrollee had stable vital signs. His lungs were clear. He had a wound vac to his left lower extremity. Regarding rehabilitation services, the enrollee received physical therapy (PT), speech therapy (ST) and occupational therapy (OT). The enrollee was at an independent to contact guard assist level with functional mobility including gait to 100 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the chest.

You asked the Plan to pre-approve the CT scan. You say that the medical records provided support the request. The Plan denied your request. The Plan says a medical need could not be confirmed for the requested CT scan.

The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee was undergoing work-up for gross hematuria and was found to have adnexal mass. The record suggests that the ordered test was requested in error. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service at this time. 

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the chest.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of services at a skilled nursing facility (SNF).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records show coverage of 100 days during this benefit period.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from June 25, 2021 to December 14, 2021. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve a continuation of services at a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for optometry care.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are participating providers in the area.

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 an out-of-network referral for optometry care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and filling (D2335) provided on August 18, 2021.
You asked the Plan to pay for the dental services. You say that this was a simple refill of a filling that fell out. You that this is the most common procedure and should be covered. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service. The Plan also says the filling is not listed as a covered service.
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 limited oral evaluation, periapical x-ray, and filling are not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and filling (D2335) provided on August 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from August 6, 2021, through August 11, 2021.
You asked the Plan to pay for hospital services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 5, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital services provided from August 6, 2021, through August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a cold and compression therapy device (NICE).  You asked the Plan to pre-approve a cold and compression therapy device. You say that the requested cold and compression therapy device is medically necessary. The Plan denied your request. The Plan says the requested cold and compression therapy device is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file and Medicare rules. The file shows that a NICE cold and compression therapy device is being requested. This device is a fluid circulating cold pad with pump. Medicare specifically denies coverage of these types of devices. Therefore, we decided that the Plan does not have to pre-approve a cold and compression therapy device (NICE).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy visits provided on April 13, 2021, to June 22, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the psychotherapy visits. You say that you would like to be reimbursed for the services. The Plan denied your request. The Plan says the provider is not 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 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 psychotherapy visits provided on April 13, 2021, to June 22, 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 unspecified preventive procedure provided on August 3, 2021.

You asked the Plan to pay for the unspecified preventive procedure. You say that your agent told you that you would not have to pay any share of any bill. You say that you told the dentist if the Plan was not paying then you do not want it. The Plan denied your request. The Plan says the service is not a covered benefit.

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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventive procedure provided on August 3, 2021.

Your complaint about this seeming like bait and switch 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an inpatient psychiatric hospital admission.  You asked the Plan to pre-approve an inpatient psychiatric hospital admission. The Plan denied your request. The Plan says based on Medicare guidelines, the mental health inpatient psychiatric services you and/or your provider are requesting do not meet the requirements for approval.  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 an inpatient psychiatric hospital admission. Our reviewer says that an inpatient psychiatric hospital admission is not medically necessary. Our physician reviewer found that based upon review the records provided it was not expected that this enrollee would improve in a reasonable period of time as she did not have dangerousness to self or others and was not showing any auditory/visual hallucinations or any aggressive behaviors. It did 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 she did not have dangerousness to self or others. The health Plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan over the entire record is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this enrollee does not meet criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to herself or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient psychiatric hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric hospital admission.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the hip.

You asked the Plan to pre-approve an MRI of the hip. You say that the medical records support the need for the requested MRI. The Plan denied your request. The Plan says the records show the same study or a test like it has been done for the enrollee. The Plan says that the prior study showed the doctor what they needed to see in order to treat the enrollee's condition.

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 an MRI of the hip. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has known metastases to the hip from esophageal cancer had a recent PET scan on November 2, 2021, with no evidence of recurrence. The enrollee has no complaints regarding the hip. Documentation does not indicate why an MRI of the hip is needed. The requested service is not reasonable or 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 an MRI of the hip have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the hip.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on July 28, 2021.

You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the eye refraction is not a covered benefit since it was medical vision check (Vitreous degeneration, bilateral). Eye refractions are only covered by your Plan if performed by a participating provider and performed as a routine screening.

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. The file shows that part of this exam was for a refraction. 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 July 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  

You asked the Plan to pre-approve the SNF services. You say that SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or daily skilled therapy in a SNF setting. The Plan says that the services needed by the enrollee are custodial in nature.  

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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no documentation that the enrollee requires skilled nursing services to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided the enrollee does not require skilled therapy services to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility at a custodial level appear appropriate in this case.  

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212) for teeth # 8 and 9 provided on August 4, 2021.

You asked the Plan to pay for the dental services. You say that you are being billed $300 for the services. You say that you still have part of your dental allowance left for the year. You also say that this amount should be covered by your dental allowance. The Plan denied your request. The Plan says the gingivectomy or gingivoplasty to allow access for restorative procedures are not listed as covered 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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth (D4212) for teeth # 8 and 9 provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the eye exam you had on August 17, 2021.  

You asked the Plan to waive the copayment for the eye exam. You say that this was a routine eye exam.  You said that you did not have floaters and were not seen for any medical condition. 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 eye exams.   

You have been asked to pay a $40 copayment for the eye exam. We looked at the medical records from this visit to determine the type of visit you had.  The medical records explicitly states that this visit was for the purpose of follow-up on floaters in the left eye.   

The records also state that you indicated that your left eye has, on rare occasion, a dart of pain and you only have stress-related headaches. You were assessed for these conditions and the doctor also checked your intraocular lens for clarity and positioning.  The doctor also removed a few lashes from your lower lid due to trichiasis. None of the above services are part of a typical routine eye exam, which is why the eye exam you had is considered a medical eye exam. 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 eye exam you had on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with an endocrinologist on August 24, 2021.

You asked the Plan to waive the copayment for the endocrinology telehealth visit. You say that the doctor sent incomplete medication information to the pharmacy, so you had to see another doctor to get a prescription. You do not think you should have to pay this copayment. 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 $45 copayment for visits with a specialist. 

You have been asked to pay a $45 copayment for the endocrinology telehealth visit. This copayment applies
regardless of your satisfaction with the visit. 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 telehealth visit you had with an endocrinologist on August 24, 2021.