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

We decided that the Plan does not have to pay for deluxe frames (V2020) progressive lens (V2781) contact lenses (V2599).

You asked the Plan to pay for the vision services. You say that the plan's claim form states the amount plan will pay is $321. You were told by a plan representative that only $125 was paid instead of $321. The Plan denied your request. The Plan says the enrollee is only entitled to $125 for eyewear benefit every year and would be responsible for any amount over the coverage limit.

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 a $125 allowance is covered every year. You are responsible for any amount above the eye wear coverage limit.

We looked at the file and the Plan's rules. The plan allows a $125 eyewear benefit every year. The plan has already paid the $125 eyewear. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.

Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) progressive lens (V2781) contact lenses (V2599).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650) provided on September 8, 2020.
You asked the Plan to pay for an LSO. You say that the requested item was legally and accurately prescribed by the physician. The Plan denied your request. The Plan says rules for payment have not been met because the enrollee did not receive a telehealth visit by the ordering physician to warrant the item billed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 an LSO. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the available documentation in the case file does not support that the requested LSO was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the LSO was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate 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 an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650) provided on September 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator provided on December 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the electrical stimulator. You say that you were told that the provider was taking care of all the paperwork. The Plan denied your request. The Plan says the provider is out of network and there was no 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 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 electrical stimulator provided on December 10, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone density scan rendered on September 23, 2020.
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 covered.
The Plan must follow Medicare rules. Medicare rules say that a bone density scan is covered once every 24 months. We looked at the file and Medicare rules. The file shows that the enrollee received a bone density scan on August 22, 2019 that the Plan approved and covered. The bone density scan on September 23, 2020 was performed less than 24 months from the previously covered scan. 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 bone density scan rendered on September 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the prosthetics provided on March 18,
2020.
You asked the Plan to waive the coinsurance for the prosthetics. You say that you would rather return the
prosthetics than pay the coinsurance. You say that the billing should be removed. The Plan denied your request.
The Plan says the coinsurance 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 20% of
the cost for prosthetic devices.
You have been asked to pay $2,701.68, which is 20% of the allowed amount for the prosthetics. The allowed
amount is $13,508.40 (20% x $13,508.40 = $2,701.68). The prosthetics fall within the "Prosthetic devices and
related supplies" 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 the prosthetics
provided on March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar brace.

You asked the Plan to pay for the provided brace. You say that physicians may inhibit innovative uses to operate their practice. The Plan denied your request. The Plan says the enrollee did not receive a video or telephonic visit by the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that spinal orthoses are only covered under certain medical indications.

We find that the lumbar brace is not supported in the medical record. Specifically, there are no medical records that show injury or a surgical procedure of the enrollee's spine. There is no testing provided to show the enrollee has weak spinal muscles or a deformed spine. There are insufficient records to show that the enrollee's mobility needs to be restricted to reduce pain. The file also does not contain documentation of an established relationship between the enrollee and the ordering provider. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar brace.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on August 12, 2019.
You asked the Plan to pay for the office visit. You say that you were not aware you needed approval to see an out-of-network provider. The Plan denied your request. The Plan says you must receive approval from our Plan before receiving care from 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 requested provider in this case is not a network provider with the Plan. 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 office visit provided by an out-of-network provider on August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Freestyle Libre therapeutic continuous glucose monitor (CGM) provided on October 22, 2020.
You asked the Plan to pay for therapeutic CGM. You say that this device was not requested by an unsolicited call, and you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this device is correct, because the enrollee was offered this item by an unsolicited telemarketing call which is prohibited by Medicare.
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 therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pay for a Freestyle Libre therapeutic continuous glucose monitor (CGM) provided on October 22, 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 the enrollee needs rehab to regain maximum function
for mobility. The Plan denied your request. The Plan says the enrollee can receive needed services in other
settings such as a skilled nursing facility or home health.
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 the complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for spinal surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care.
There is not a reasonable expectation that this patient 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from December 24, 2019, to January 10, 2020.
You asked the Plan to pay for this service. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. The Plan says that the claim was billed with an invalid type of bill for a non-participating provider. The Plan states that there is corrected claim submitted with bill type 329, but the claim is still missing the required home health data (i.e G code and RAP claim). The Plan states they would accept a corrected claim if submitted by the provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, both the original claim and the corrected claim cannot be paid as billed due to the omission of the appropriate codes that allow payment. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from December 24, 2019, to January 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the elbow x-ray, wrist x-ray, ED visit, and pharmacy services provided on September 20, 2020.
You asked the Plan to pay for the elbow x-ray, wrist x-ray, ED visit, and pharmacy services. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the elbow x-ray, wrist x-ray, ED visit, and pharmacy services provided on September 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on December 30, 2019.
You asked the Plan to pay for the dental service. You say that the dental office called the plan and was advised the service was approved. You say that you have been receiving statements that say you owe $145. You say that you are not working. You say that you were advised by a plan representative that you had money in an account for dental services. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network providers may bill you for the difference between what was billed and what was paid.
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 and extractions are a covered service, out of network providers may bill you for the difference between what was billed and what was paid. The record shows that the provider was paid at the Maximum Allowable Charge (MAC). Therefore, we decided that the Plan does not have to pay for the extraction provided on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee braces (L2397, L1833) provided on September 16, 2020.
You asked the Plan to pay for knee braces. You say that this should be covered. The Plan denied your request. The Plan says the records do not show that the ordering physician is the enrollee's treating physician.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. A proof of delivery was not included in the submitted documentation. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for knee braces (L2397, L1833) provided on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on
September 14, 2020.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 a domiciliary or rest home visit provided on September 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided by an out of network (OON) provider.

You asked the Plan to pay for the physical therapy services. You say that you were told you could be seen by anyone at the clinic while out of the service area and it would be covered. The Plan denied your request. The Plan says the provider is out of network and there was no 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 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 physical therapy services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interim partial denture (D5820), a custom fabricated abutment (D6057), and an implant supported crown (D6066).
You asked the Plan to pre-approve the dental services. You say that you need a dental implant for your front tooth. You say that a bridge will not suffice as the surrounding teeth are week and cracked and would in turn impact the surrounding teeth in a negative way. You say that you need this replacement done as soon as possible otherwise the tooth may fall out unexpectedly. The Plan denied your request. The Plan says the requested services are not listed as covered. The Plan also says that any services not listed 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an interim partial denture (D5820), a custom fabricated abutment (D6057), and an implant supported crown (D6066).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve Ondansetron. You say that the enrollee is currently undergoing chemotherapy treatment. The Plan denied your request. The Plan says the medication has been prescribed for a period that exceeds the time frame.
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 Ondansetron.
Benefits for Ondansetron 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metronidazol 0.75% gel.
You asked the Plan to pre-approve Metronidazol. You say that Metronidazol is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B 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 Metronidazol 0.75% gel.
Benefits for Metronidazol 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for your medical condition. The Food and Drug Administration (FDA) indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. You have multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records provided. There is imaging evidence of scoliosis of the lumbar spine with no documentation of the Cobb angle. Additionally, the dual-energy x-ray absorptiometry (DEXA) scan has demonstrated osteopenia. Therefore, the requested service is considered not medically reasonable or 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).