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

We decided that the Plan does not have to pay for the ophthalmology services provided on September 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the ophthalmology services. You say that you were directed to the eye specialist by your primary doctor for these specific tests. These tests were necessary as it determined it is no longer safe for you to drive. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 has network providers available who can provide 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 ophthalmology services provided on September 10, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Ultra test strips (A4253).
You asked the Plan to pre-approve the One Touch Ultra test strips. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no medical reason documented as to why the member cannot use a preferred brand.
The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. 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 One Touch Ultra test strips. Our reviewer says that the provided documentation did not clearly show sufficient support for using the requested One Touch Ultra Test Strips over any of the preferred testing strip options. As all strips are very similar in accuracy and effectiveness for the purpose of checking glucose readings independently, there is no inherent benefit of using the requested testing strips over the preferred strip brands Our physician reviewer found One Touch Ultra Test Strips will be considered 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 the One Touch Ultra test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve One Touch Ultra test strips (A4253).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 12, 2019 to the enrollee
by an out of network (OON) provider.
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 rendered by an out-of-network provider without prior authorization.
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 has network providers
available who can provide 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 medical services provided on March 12, 2019
to the enrollee by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 12, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you shouldn't have to pay for the consultation because you are still having problems after surgery. The Plan denied your request. The Plan says the copayment applied 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 per specialist office visit. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea MyoPro myoelectric orthosis (L8702).You asked the Plan to pre-approvethe MyoPro orthosis. You say that  The Plan denied your request. The Plan says the MyoPro myoelectric orthosis as not a covered item as they are considered experimental and investigational because their effectiveness has not been established.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 MyoPro orthosis. Our reviewer says that the (CPT) code L8702 (powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated) (MyoPro Orthosis) is not medically necessary for the enrollee per the Social Security Act, Section 1862(a)(1)(A). Our physician reviewer found the MyoPro Orthosis is not the most appropriate available supply or level of service for the enrollee in question considering potential benefits to the enrollee. It is not known to beeffective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, improve his hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase his participation in bimanual activities.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 MyoPro orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvea MyoPro myoelectric orthosis (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #20.
You asked the Plan to pre-approve the crown. You say that you need the crown because your molars are very
deteriorated. The Plan denied your request. The Plan says there is no evidence of active recurrent cavities.
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
service is not medically necessary. Our physician reviewer found the provided x-rays do not indicate any
defects at the margins of the tooth in question, nor any apparent fracture of porcelain or substructure. There is
no clinical information provided to support a claim of necessity. Necessity to replace a crown is based on there
being a defect of such significance that the crown would fail due to caries that affect the margins that is not
repairable, and fracture of the substrate such that it becomes nonfunctional or causes a periodontal trap area or
other defect. Our reviewer found that absent a showing of any of the above potential problems by clinical
notes, radiographs or intraoral photos there cannot be a finding of medical necessity for replacement of a
crown. Our physician reviewer also found that there has been no supporting evidence supplied to address the
need for the requested service and therefore it must be found not necessary.
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 for tooth #20.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says that the
services requested could be delivered in an alternate setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. The
documentation does not support that the enrollee in this case requires services at the LTACH that are not
available at the acute care hospital where he is currently receiving care. There are no required medical services
identified that are available at the LTACH, that are not available at the current health care setting being offered
by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria
for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an elbow strap (A4467).
You asked the Plan to pay for the elbow strap. You say that this should be covered. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover the elbow strap coded (A4467). Therefore, we
decided that the Plan does not have to pay for an elbow strap (A4467).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forthe elastographyultrasound rendered to enrollee on August 16, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the diagnosis is not supported.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase 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 medically necessary. Our physician reviewer found elastography is beneficial inthe determination of the severity of liver disease. It offers the benefit of being non-invasive and can give significant information regarding the degree of liver disease. The elastography was reasonable and medically necessary for the enrollee.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 been met.Therefore, we decided that the Plan has to pay forthe elastography ultrasound rendered to enrollee on August 16, 2019.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 pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 28, 2019. You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a necessary service. The Plan denied your request. The Plan says payment of this service is included in the DRG payment. The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the wound care services and clinic visits provided from August 20, 2019 to November 26, 2019.
You asked the Plan to reduce the copayments for the wound care services and the clinic visits. You say that the location you received the wound care is not located at the hospital. You say you were told you would have a $30 to $35 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 $175 copayment for each Medicare-covered outpatient admission to ambulatory surgical center. You have been asked to pay a total of $2,460.03 for the wound care services and the clinic visits. The wound care services and the clinic visits fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient facility. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
August 20, 2019
Wound care
$278.80
$175
$175.00
August 23, 2019
Clinic visit
$102.84
$175
$102.84
August 27, 2019
Wound care
$156.63
$175
$156.63
August 30, 2019
Clinic visit
$102.84
$175
$102.84
September 6, 2019
Clinic visit
$102.84
$175
$102.84
September 10, 2019
Wound care
$278.80
$175
$175.00
September 13, 2019
Clinic visit
$0
$175
$0
Date of Service
Service
Allowed Amount
Copayment
Member Liability
September 17, 2019
Wound care
$278.80
$175
$175.00
September 20, 2019
Wound care
$156.63
$175
$156.63
September 27, 2019
Wound care
$278.80
$175
$175.00
October 1, 2019
Clinic visit
$0
$175
$0
October 4, 2019
Clinic visit
$0
$175
$0
October 8, 2019
Wound care
$278.80
$175
$175.00
October 11, 2019
Clinic visit
$0
$175
$0
October 15, 2019
Wound care
$278.80
$175
$175.00
October 18, 2019
Clinic visit
$0
$175
$0
October 22, 2019
Wound care
$156.63
$175
$156.63
October 29, 2019
Wound care
$156.63
$175
$156.63
November 1, 2019
Clinic visit
$102.84
$175
$5.10
November 8, 2019
Wound care
$156.63
$175
$156.63
November 12, 2019
Wound care
$156.63
$175
$156.63
November 26, 2019
Wound care
$156.63
$175
$156.63
Total
$2,460.03
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 reduce the copayments for the wound care services and clinic visits provided from August 20, 2019 to November 26, 2019.
Your complaint about fraudulent charges 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 pay for the acute inpatient hospital care provided from April 21, 2016 through April 22, 2016.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 21, 2016 through April 22, 2016.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on October 28, 2019.You asked the Plan to pay for the hearing aids. You say that you have done business with Rexall Center for many years and have been satisfied with their service. one of the aids broke last month and since both were 5 years old you decided to get a new pair.The Plan denied your request. The Plan says enrollee's must receive hearing services from a participating provider.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 when provided by a participating provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreye examination and eyewear provided July 23, 2019.You asked the Plan to pay forthe vision services. You say that you thought you had until March 2020 to send the reimbursement and you request an exception this time to help you out.The Plandenied your request. The Plan says this claim was submitted 125 days after the date of service which is outside the standard timely filing limit of 90 days.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the vision services was not filed until November 25, 2019.  Per the plan's contract you must submit your reimbursement for the Flex Benefit within 90 days of the date you received the service or item This means that more than 90 days from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay foreye examination and eyewearprovided July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on May 21, 2019.You asked the Plan to payfor the train of four monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says train of four is considered integral to the primary procedure and therefore is part of a bundled payment.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in the record. Specifically, payment for train of four monitoring is bundled with the payment for the primary neuromonitoring procedure and not separately payable. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on May 21, 2019.