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

We decided that the Plan does not have to reimburse you for eyeglasses provided on February 24, 2021.
You asked the Plan to reimburse you for the eyeglasses. You say that this should be covered as the prescription was obtained from the Plan's vision care provider. The Plan denied your request. The Plan says eyeglasses must be purchased through the Plan's vision care provider.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the Plan's vision care provider. We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's vision care provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on August 15, 2019 by out of network provider.
You asked the Plan to pay for the vision services. You say that you feel this should be covered because you have been seen by this provider before. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an out of network provider.
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 rendering 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 vision services provided on August 15, 2019 by out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport
(A0998) provided on April 21, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your
insurance covers ambulance services, and you believe this service should be covered even though you were not
transported to the hospital. The Plan denied your request. The Plan says you were not transported and therefore
there is no coverage.
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 on April 21, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
You advised that you did not want to be transported to the hospital because you were transported last year and
nothing was done. Therefore, we decided that the Plan does not have to pay for the ambulance response and
treatment with no transport (A0998) provided on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on March 11, 2021.
You asked the Plan to pay for the eye exam. The Plan denied your request. The Plan says you must use the Plan's vision
provider.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when
provided by the Plan's vision provider.
We looked at the file and the Plan's rules. The file shows that the eye exam was not provided by the Plan's vision
provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met.
Therefore, we decided that the Plan does not have to pay for an eye exam provided on
March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on August 1,
2019.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says services provided by
non-participating providers are excluded.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services when provided.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we
decided that the Plan does not have to pay for eyeglasses provided by on August 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on August 29, 2019.
You asked the Plan to pay for the eyeglasses. You say that you were traveling and your eyeglasses broke. You
say that you saw a physician to have your eyeglasses fixed, and you did not know he was not in the
network. The Plan denied your request. The Plan says you must purchase your eyewear from a
participating provider and your plan does not offer out of network benefits.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services when purchased from a plan provider.
We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the
Plan. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been
met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchase made November 4, 2020.
You asked the Plan to pay for the eyewear purchase. You say that you were not aware of changes made to the Plan's vision care policy. The Plan denied your request. The Plan says items and services purchased outside of the Plan's provider network are not covered.
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 covers these services when purchased through a plan provider. We looked at the file and the Plan's rules. The eyewear purchase was made outside of the Plan's provider network. Based on this information, we decided that the Plan's rules for coverage of the eyewear purchase have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear purchase made November 4, 2020.
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 admission to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for inpatient rehabilitation is not met, and the enrollee's necessary care can be provided in another setting.

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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses provided on February 18, 2021.
You asked the Plan to pay for the progressive lenses. The Plan denied your request. The Plan says eyewear coverage is provided by the Plan's vision provider.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the Plan's vision provider.
We looked at the file and the Plan's rules. The file shows that the eyewear was not provided by the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for eyeglasses provided on December 7, 2020.
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says that there are no benefits available for out-of-network providers.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan benefit allows coverage for eyewear either from a Plan vision provider or a non-Plan vision provider. Therefore, we decided that the Plan has to pay for eyeglasses provided on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92014) received December 3, 2020 from the
out-of-network provider.
You asked the Plan to pay for the eye exam. You say that this provider is the only one specialized in fitting your contact lenses. The Plan denied your request. The Plan says no referral is required for an annual routine eye exam, but you must use a provider in the network.
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 covers these services when received from a non provider. We looked at the file and the Plan's rules. The Plan contract states you must use an plan provider. Your provider in this case does not participate in the Plan's vision care network. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam (92014) received December 3, 2020 from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lenses and frames (V2025, V2100) received January 12, 2021.
You asked the Plan to pay for the lenses and frames. You say that you were not told that this provider was now out-of-network. The Plan denied your request. The Plan says services with a non provider are not covered.
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 covers these services when received from a non provider. We looked at the file and the Plan's rules. The provider in this case is outside of the Plan's vision network. Based on this information, we decided that the Plan's rules for coverage of the lenses and frames have not been met. Therefore, we decided that the Plan does not have to pay for the lenses and frames (V2025, V2100) received January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a refraction (92015) provided on September 8, 2020.
You asked the Plan to pay for a refraction. You say that this should be retro-authorized. The Plan denied your request. The Plan says this is not covered.
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 covers these services when they are provided though the Plan's vision care network. We looked at the file and the Plan's rules. Routine eye exams, such as refractions, are covered only when provided through the Plan's vision network. Based on this information, we decided that the Plan's rules for coverage of a refraction have not been met. Therefore, we decided that the Plan does not have to pay for a refraction (92015) provided on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the substitute skin graft for chronic ulcer on left foot, for the enrollee.
You asked the Plan to pre-approve the substitute skin graft. You say that you believe the enrollee will benefit from this treatment. The Plan denied your request. The Plan says the enrollee first sought treatment for this wound on June 1, 2021. The Plan states the treatment has not been ongoing for greater than four (4) weeks, so the criteria is not met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the substitute skin graft. Our physician reviewer found the record indicates that the enrollee has chronic venous insufficiency and type 2 diabetes. The record indicates that the enrollee has a non-pressure ulcer after trauma on the ankle. The record indicates that the provider believes this is a venous insufficiency ulcer has the enrollee has 4+ edema. The record does not indicate that the enrollee has diabetic neuropathy.
The record does not indicate that the enrollee has had adequate wound care for a period of at least 30 days. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 substitute skin graft have not been met. Therefore, we decided that the Plan does not have to pre-approve the substitute skin graft for chronic ulcer on left foot, for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the sales tax (D9985) from the dental services provided on March 26, 2021.

You asked the Plan to pay for the sales tax (D9985). You say that you were informed a tooth had to be extracted due to infection and the dentist was able to do an emergency procedure. You say that this was not a dental procedure, but a lifesaving procedure and you are appealing the denials. The Plan denied your request. The Plan says the nitrous oxide inhalation will be paid and the sales tax is not a covered benefit.

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 D9985 is not covered. Specifically, sales tax is not covered by Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of the sales tax (D9985) have not been met. You may wish to verify if your state or local government allows/requires sales taxes to be charged on fees for dental services. Therefore, we decided that the Plan does not have to pay for the sales tax (D9985) from the dental services provided on March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom G6, for the enrollee.

You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who 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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

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, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the item have not been met. There was no confirmation that the enrollee is being insulin-treated with three or more daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump and the enrollee is not on medications for diabetes and last hemoglobin A1C is 5.7. Therefore, we decided that the Plan does not have to pre-approve Dexcom G6, for the enrollee.
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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower 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 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for abdominal pain, weakness,
hyponatremia, pulmonary hypertension, tachy-brady syndrome and a urinary tract infection. Your medical
conditions 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. You do require physical and occupational therapy but there is no documented need for an
intensive rehabilitation program. Medically necessary services can be provided in a different level of care.
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. Our physician reviewer found that your condition does not
meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment provided on March 30, 2021 by an out-of-network provider.

You asked the Plan to pay for the trans-urethral prostate tissue ablation system treatment. You say that you wanted this procedure and did not want to wait for authorization. The Plan denied your request. The Plan says you do not have out-of-network benefits.

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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the treatment provided on March 30, 2021 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on December 15, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a post-operative visit for a routine colonoscopy and the global period should apply. The Plan denied your request. The Plan says you have been asked to pay 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 $45 copayment for services obtained form an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. Please note, there is no provision in the contract which states a copayment for a surgical follow-up visit will be waived.
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 specialist office visit provided on December 15, 2020.