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

We decided that the Plan does not have to pre-approve Gabapentin 100 mg capsule.
You asked the Plan to pre-approve Gabapentin. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical
benefit.
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 Gabapentin 100 mg
capsule.
Benefits for Gabapentin may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 you were admitted for seizures and was discharged to skilled nursing on September 17, 2021. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve physician services. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network physicians available to provide these 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 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 physician services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient mental health admission.

You asked the Plan to pre-approve the acute inpatient mental health admission. The Plan denied your request. The Plan says an acute inpatient mental health admission is not medically necessary at this time.

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 the acute inpatient mental health admission. Our reviewer says that the admission of this patient does not meet the criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to himself or others but was without agitation or aggression without perceptual disturbance including auditory or visual hallucinations. Our physician reviewer found this enrollee does not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It does not appear that active treatment
was taking place. Our reviewer found that it does not appear that the services are reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. Our physician reviewer also found that it does appear that the records were supervised and evaluated by a physician.

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 acute inpatient mental health admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient mental health admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care provided on May 23, 2021.
You asked the Plan to pay for observation care. You say that the provider rendered services to the patient in
good faith that the in-network facility would obtain the proper referrals and authorizations. The Plan denied
your request. 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. We have also determined 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 did not pre-approve the
services at issue. The Plan file shows that the referring provider/hospital is not a network provider. We found
no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not
have to pay for observation care provided on May 23, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on April 7, 2021.
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 billed with an appropriate primary diagnosis code.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate primary diagnosis code. Sequela codes are not billable as the primary diagnosis. 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 emergency room (ER) services rendered on April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an OON
provider.
You asked the Plan to pre-approve an outpatient surgery. You say that you would like to use an out-of-network
provider. The Plan denied your request. The Plan says there are in-network providers available for these
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 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 outpatient surgery to be provided by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam you had on May 21, 2021.

You asked the Plan to waive the copayment for the medical eye exam. You say that this was a routine annual eye exam so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly because this was a medical eye exam.

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 $10 copayment for medical eye exams. 

You have been asked to pay a $10 copayment for the medical eye exam. The medical records show that you were seen not for an annual exam, but rather for an evaluation for symptomatic dry eye syndrome. That is why the eye exam falls within the medical eye exams 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 medical eye exam you had on May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayments for specialist visits provided from March 11, 2021, to March 25, 2021.

You asked the Plan to waive the deductible and copayments for specialist visits. You say that you disagree with how the claims were processed. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $203 deductible which applies to physician/practitioner services, including doctor's office visits. Your contract with the Plan also says that after the $203 deductible has been met, enrollee's must pay a $30 copayment for specialist visits.

You had specialist visits from March 11, 2021, to March 25, 2021. The record shows that you had only paid $79.93 toward the $203 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible charges. After the deductible has been met, you are also responsible to pay a $30 copayment for specialist visits.

The total amount you owe is: $183.07. 

The item or service you asked the Plan to waive the deductible and copayments for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible which applies to physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time specialist visits were received on March 11, 2021 to March 25, 2021. Therefore, we decided that the Plan does not have to waive the deductible and copayments for specialist visits provided from March 11, 2021, to March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020) provided on December 29, 2020.
You asked the Plan to pay for eyeglass frames. You say that you had cataract surgery and visited this provider for glasses after your surgery. You also say that the provider is not approved for post cataract surgery eyewear. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.
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 contract says that your plan covers standard eyewear after cataract surgery. The Plan does not cover enhanced upgrades to the standard eyewear such as lens options. The Plan contract also says that you receive a $100 vision allowance every two years for routine eyewear, including the lenses and one pair of eyeglass frames or contact lenses. We looked at the file and the Plan's rules. The records show you exhausted your $100 maximum allowed benefit on December 29, 2020. The records also show the claims were submitted under your routine vision benefit. The total cost for your eyeglasses is $297. Your vision allowance was applied, leaving you with a balance of $197 ($297 - $100 = $197). Based on this information, we decided that the Plan's rules for coverage of eyeglass frames have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020) provided on December 29, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the ER visit and self-administered drugs provided from March 21, 2021, through March 23, 2021.
You asked the Plan to waive the cost for the ER visit and self-administered drugs. You say that she was a danger to herself and you had no alternative but to call the EMS to take her to the hospital. You say that you assumed the medications that were necessary to calm her would be paid by insurance. The Plan denied your request. The Plan says the copayment for the ER visit applied correctly. The Plan also says that the claim for the drops were processed to pay $743.88 and the remaining drugs are denied.
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 20% coinsurance but no more than $50 for each emergency room visit. The enrollee has been asked to pay a $50 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. 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. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. 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 waive the cost for the ER visit and self-administered drugs provided from March 21, 2021, through March 23, 2021
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for a screening test of visual acuity (99173) provided on April 12, 2021.
You asked the Plan to hold you harmless for a screening test of visual acuity. You say that this test was always covered in the past and the test was performed during your annual wellness exam. The Plan denied your request. The Plan says that the service is not a covered benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You had a screening test of visual acuity by a contract provider. The file does not show that the Plan provided notice that a screening test of visual acuity would not be covered. Under Medicare rules, this means a screening test of visual acuity is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for a screening test of visual acuity (99173) provided on April 12, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for urology services provided on March 3,
2021.

You asked the Plan to waive the deductible for the urology services. You say that you have been trying to
ascertain the correct amount owed on this claim. The Plan denied your request. The Plan says a $150
deductible.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The
contract with the Plan says that there a $150 deductible that applies to medical services. The only exceptions to
this deductible are Part D drugs, Health and Wellness education programs, Worldwide Coverage, and
Coronavirus (COVID-19) tests and treatment. The enrollee had not paid anything towards the deductible in
2021 at the time of the services, so the full allowed amount of $132.18 has been applied to the deductible. The
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 annual deductible.
This cost sharing is a contractual obligation that had not been met at the time the services was received on
March 3, 2021. Therefore, we decided that the Plan does not have to waive the deductible for urology services
provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nasal endoscopy for post-operative debridement following
functional endoscopic sinus surgery, nasal and/or sinus cavity(s), unilateral or bilateral (CPT code S2342)
provided to the enrollee on March 3, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request.
The Plan says this code is not a valid code for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Based on this information, we decided that Medicare rules for coverage of the service have not been met. Code
S2342 is assigned a status code "I" equals Not valid for Medicare purposes. Medicare guidance says status code
"I" Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these
services. Therefore, we decided that the Plan does not have to pay for nasal endoscopy for post-operative
debridement following functional endoscopic sinus surgery, nasal and/or sinus cavity(s), unilateral or bilateral
(CPT code S2342) provided to the enrollee on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #3.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says there is minimal loss of tooth structure on the biting surface and there is no evidence of decay between tooth #3 and the teeth next to it.
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 the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the documentation provided does not meet the criteria for coverage for a crown restoration for tooth #3. Our physician reviewer found tooth #3 does not appear to have significant coronal breakdown due to caries or fracture to warrant a crown restoration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #3.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Japanese-style acupuncture services, one or more needles, without electrical stimulation (97811).
You asked the Plan to pre-approve the acupuncture services. You say that you were advised by your PCP to get acupuncture services for your mobility and spinal curvature issues. You have completed 4 sessions with good effect and would like these services to continue. The Plan denied your request. The Plan says there is no documentation showing that you have chronic low back pain.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the acupuncture services is being requested for your mobility and spinal curvature issues. Therefore, we decided that the Plan does not have to pre-approve the Japanese-style acupuncture services, one or more needles, without electrical stimulation (97811).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for a spinal bone growth
stimulator and a back brace.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says these items are available in the plan's network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the 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
a referral out-of-network for a spinal bone growth stimulator and a back brace.