Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids.

You asked the Plan to pay for these services. You say that you were not advised that the provider was not in-network. The Plan denied your request. The Plan says the services are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only from a network hearing aid supplier.

We looked at the file and the Plan's rules. The file shows that you purchased hearing aids from a provider that is not a network hearing aid supplier with the Plan. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home dialysis services.

You asked the Plan to pay for home dialysis services. You say that these services should be covered. The Plan denied your request. The Plan says these services were not rendered by a provider that is enrolled in Medicare.

The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.

We looked at the file and Medicare rules. The record shows that the provider of the services at issue is not enrolled in Medicare. Based on this information, we decided that Medicare rules for coverage of home dialysis services have not been met. Therefore, we decided that the Plan does not have to pay for home dialysis services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the lumbar spine for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is needed to determine if surgery is needed. The Plan denied your request. The Plan says that the records do not show a failure of conservative therapy.

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 the MRI. Our reviewer says that the requested MRI is medically reasonable or necessary. Our physician reviewer found the plan has applied Milliman Care Guidelines which are not binding upon the Independent Review Entity. Under Medicare rules, MRIs are covered when medically necessary and reasonable for the diagnosis or treatment of the specific patient involved. In this case, the enrollee is having increased symptomatology, not responding to his usual therapy nor to a trial of physical therapy. Given the new onset weakness of the lower extremities, it is medically reasonable and necessary to perform an MRI to assess for pathology that could require further intervention. Therefore, the coverage criteria are satisfied and the MRI lumbar spine is recommended.

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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the lumbar spine for the enrollee.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair lift.

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 are not a covered benefit.

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. Therefore, we
decided that the Plan does not have to pay for the wheelchair lift.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from September 17, 2020, to September 19, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $95 copayment for each day for days 1-5 per admission for Medicare-covered inpatient hospital care. You have been asked to pay a $95 copayment for each day of the inpatient hospital stay. ($95 x 2 days = $195). The inpatient hospital stay falls within the "Inpatient Hospital Care" benefit category. The medical record shows you were admitted on September 17, 2020 and discharged on September 19, 2020.
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 inpatient hospital stay provided from September 17, 2020, to September 19, 2020.
Your complaint that the procedure was not done properly 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for toric (astigmatism-correcting) lenses provided July 10, 2020.
You asked the Plan to pay for the toric lenses. You say that the lenses should be covered. The Plan denied your request. The Plan says only convention lenses are covered. If the enrollee recieves an A-C IOL, they are responsible for the cost difference.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for toric (astigmatism-correcting) lenses provided July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service, by report, (D1999) provided on October 20, 2020.
You asked the Plan to pay for the unspecified preventive service. You say that the dental office called the plan to verify your benefits. You say that they printed off your benefit chart. You also say that you would not have had these procedures done if you knew they were not in network. The Plan denied your request. The Plan says the unspecified preventive service, code D1999, was used to indicate personal protective equipment. The Plan also says that personal protective equipment 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 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 service, by report, (D1999) provided on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0470, D4346, D4921, and D9630) you received on November 9, 2020, and November 10, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services are not covered.
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 services are not among those covered under this benefit. The Plan covers only those dental services for which the codes are listed in the Evidence of Coverage. Dental codes D0470, D4346, D4921, and D9630, are not listed, and therefore are not covered. Therefore, we decided that the Plan does not have to pay for the dental services (D0470, D4346, D4921, and D9630) you received on November 9, 2020, and November 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650).

You asked the Plan to pay for a lumbar-sacral orthosis. You say that the enrollee is using the item and the item is helping the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that a spinal orthosis is covered when it is ordered for one of several specified indications as outlined in this letter 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 pay for a lumbar-sacral orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was lower back pain. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650).
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 the IRF admission is medically necessary. The Plan
denied your request. The Plan says your needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 based on the medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an
IRF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service (A0429).

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not payable as you were not transported by the ambulance.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport by the billing party, neither Medicare nor the Plan pays for the service provided. Therefore, we decided that the Plan does not have to pay for the ambulance service (A0429).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided on July 9, 2020.
You asked the Plan to pay for the neuromuscular stimulator (E0745). You say that the documents show
medical necessity. The Plan denied your request. The Plan says the documentation indicates services are not
necessary for treatment of the enrollee's condition.
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 the neuromuscular stimulator (E0745). Our
reviewer says that the neuromuscular stimulator is not medically necessary. Our physician reviewer found the
documentation in the case file does not support that the requested neuromuscular stimulator was medically
reasonable and necessary for the enrollee in this case. A physical examination of the ankles and feet would
reasonably be required to adequately assess whether the coverage criteria were met. The documentation does
not support that the neuromuscular stimulator was medically reasonable and necessary in this case, as there is
insufficient documentation of a credible evaluation with a credible physical examination of the ankles and feet.
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 neuromuscular stimulator (E0745) have not been met. Therefore, we
decided that the Plan does not have to pay for the neuromuscular stimulator provided on July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and sleeves (L1833, L2397) purchased September 21, 2020.
You asked the Plan to pay for the knee orthoses and sleeves. You say that the items provided were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there was no established relationship between the enrollee and the ordering physician.
The Plan follows Medicare rules. Medicare rules say that for the requested knee orthosis to be covered, knee instability must be documented by examination of the beneficiary and objective description of joint laxity 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 the knee orthoses and sleeves. Our reviewer says that the items were not reasonable and necessary. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 knee orthoses and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and sleeves (L1833, L2397) purchased September 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery (67904) provided December 28, 2017.
You asked the Plan to waive the coinsurance for the outpatient surgery. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct amount was applied.
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% coinsurance for out-of-network outpatient surgical services. You have been asked to pay a 40% coinsurance for the outpatient surgery. The outpatient surgery falls within the out-of-network outpatient surgical 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 coinsurance for outpatient surgery (67904) provided December 28, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on October 20, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you believe that these services should have been covered in full. The Plan denied your request. The Plan says this claim was processed appropriately.
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 for services provided OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on October 20, 2020 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from September 22, 2020, to October 13, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the requested service was not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 22, 2020, to October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear protection plan you received on October 2, 2020.
You asked the Plan to pay for the protection plan. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. While Medicare and your Plan covers eyeglasses after cataract surgery, the requested protection plan is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the eyewear protection plan you received on October 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on October 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. 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 the medical services provided to you by an out-of-network
provider on October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove Freestyle Libre/Sensor/Flash Monitoring System (continuous blood glucose system sensor or CGM).
You asked the Plan to preapprove the CGM. You say that you don't want to prick your finger several times a day. The Plan denied your request. The Plan says you do not meet coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove Freestyle Libre/Sensor/Flash Monitoring System (continuous blood glucose system sensor or CGM).