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

We decided that the Plan does not have to pay for deluxe frame, sphere single vision (V2020) progressive lens
(V2781) provided September 26, 2019.
You asked the Plan to pay for the vision services. You say that you're appealing because it was your
understanding you were allowed $200 for frames every two years. You are only requesting payment for frames
not the total cost. The Plan denied your request. The Plan says enrollee's must receive their medical services
from an in-network provider.
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 rendered by an in-network provider.
We looked at the file and the Plan's rules. Services rendered by an out of network provider are not covered by
the plan. 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 frame, sphere single vision
(V2020) progressive lens (V2781) provided September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use (D9630) or pay more for the comprehensive oral evaluation (D0150) and simple extraction (D7140) 
provided on April 28, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the drugs or medicaments and to pay more for the comprehensive oral evaluation 
and simple extraction. You say that the treating provider is in-network with the Plan. You also say that you 
should not have to pay the amount you are being charged because the provider's office billed you incorrectly.

The Plan denied your request. The Plan says the drugs or medicaments is not a covered service. The Plan also 
says that the treating provider does not have a contract with the Plan as a participating provider and is allowed 
to bill the difference of the allowed amount and their billed amount to you.

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 drugs or medicaments dispensed in 
the office for home use (D9630) is not among those covered under this benefit. You are also responsible for the 
difference between the billed amount and allowed amount because these services were rendered by an OON 
provider. Therefore, we decided that the Plan does not have to pay for the drugs or medicaments dispensed in 
the office for home use (D9630) or pay more for the comprehensive oral evaluation (D0150) and simple 
extraction (D7140) provided on April 28, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the two Bevacizumab injections provided on May 29, 2020.
You asked the Plan to waive the coinsurance for the Bevacizumab injections. You say that the enrollee was not made aware of an option to continue receiving treatments at her local doctor's office. You also say that the enrollee was not advised of the increased payment she would incur due to the change of location. The Plan denied your request. The Plan says the copayment amount that the enrollee is being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. The allowed amounts of these drugs total $39.78, resulting in a coinsurance amount of $7.96. The enrollee has been asked to pay a 20% coinsurance for the Bevacizumab injections. Bevacizumab injections falls within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the two Bevacizumab injections provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zostavax vaccine provided on August 25, 2021.

You asked the Plan to pay for the services provided. You say that you needed the vaccine to protect yourself. The Plan denied your request. The Plan says this is not a covered service.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services provided. The Plan follows the same rules. 

The records do not show that you have been injured or directly exposed to any illness related to the services provided. Therefore, we decided that the Plan does not have to pay for the Zostavax vaccine provided on August 25, 2021.

Benefits for the services provided 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle lite test strips.

You asked the Plan to pre-approve Freestyle lite test strips. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has will only cover Freestyle test strips and monitors. Other brands of test strips or monitors will NOT be covered by the plan. 

Review of the file shows that you are requesting a brand of test strips for the enrollee that is not Freestyle brand. The Plan has brands available who can provide the items at issue in this appeal. The documentation does not support that the enrollee has tried and failed the covered test strips. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve Freestyle lite test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) electrocardiogram (ECG) with at least 12 leads (93000) provided on July 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you wish to appeal this decision. This was your regular doctor and not a specialist, so you do not need prior authorization to consult him. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 outpatient office visit (99213) electrocardiogram (ECG) with at least 12 leads (93000) provided on July 9, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 3, 2021.  

You asked the Plan to pay for the dental service. You say that you had gone to the dentist for a temporary filling. You say that you did not go for an oral evaluation. You also say that you had to return to get a permanent filling. The Plan denied your request. The Plan says oral exams are covered once every 6 months. The Plan also says that the frequency limit has been exceeded. 
 
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 oral exams are covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periodic oral exam that you received on April 29, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on August 27, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the endodontic therapy. You say that your dentist referred you to this treating facility for the root canal because your provider does not perform root canals. You also say that you do not understand why the provider choosing not to receive Medicare funds results in a denial of this claim for you to receive reimbursement for what you have already paid. The Plan denied your request. The Plan says you received this service from a provider who chose not to receive Medicare funds. The Plan also says that payment cannot be issued for services performed by a provider who has opted out of Medicare.
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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on August 27, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pontic (D6242) and three retainer crowns (D6752 x3) provided on September 20, 2021.  You asked the Plan to pay for the pontic and retainer crowns. You say that the Plan advised you that these services would be covered. You also say that you pay an extra premium each month to be sure you would be covered. The Plan denied your request. The Plan says these services are not covered under your dental plan. The Plan says that your provider contacted the Plan prior to this date of service verify benefits and was advised that these services would not be covered. The Plan also says that when you contacted the Plan on December 4, 2020, you were not advised that a pontic and retainer crown would be covered under your policy.  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 pontic (D6242) and three retainer crowns (D6752 x3) provided on September 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the five skilled nursing visits (G0299 x5) provided from April 20, 2021, to May 12, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the skilled nursing visits. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says prior authorization was not obtained from the Plan. The Plan also says that the enrollee already had an authorization on file to a contracted agency.

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 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 five skilled nursing visits (G0299 x5) provided from April 20, 2021, to May 12, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor.

You asked the Plan to pre-approve a Freestyle Libre 2 Sensor. You say that the item is medically necessary.
The Plan denied your request. The Plan says the member does not meet the criteria for this item.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
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 assess 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 use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
Freestyle Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Freestyle Libre 2 Sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

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. Our physician reviewer found based on the documentation provided the enrollee appears to not be stable enough for transfer at this time. Acute care services can be safely administered at the current facility for the time being until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. 

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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.

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 Fasenra.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of desensitizing resin for cervical and/or root surface (D9911) and two occlusal adjustments (D9951 x2) provided on June 3, 2021.

You asked the Plan to pay for the application of desensitizing resin and occlusal adjustments. You say that you were not advised by the Plan or the provider that there would be any additional charges for the filling. You also say that you did not receive an occlusal adjustment. 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the application of desensitizing resin for cervical and/or root surface (D9911) and two occlusal adjustments (D9951 x2) provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364), pulp vitality tests (D0460), and endodontic therapy (D3330) provided on September 7, 2021.

You asked the Plan to pay for the cone beam CT capture and interpretation, pulp vitality tests, and endodontic therapy. You say that these services were necessary because you were in pain and had an infected root canal. You also say that the services provided were necessary to properly diagnose the problem and reasonable and dentally necessary to provide the appropriate dental services. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan.

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 cone beam computed tomography (CT) capture and interpretation (D0364), pulp vitality tests (D0460), and endodontic therapy (D3330) provided on September 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

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. Our physician reviewer found based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. 

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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Queen Flexible Bed.

You asked the Plan to pre-approve a Queen Flexible Bed. You say that this item is medically necessary. The
Plan denied your request. The Plan says this item does not primarily serve a medical purpose.

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. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a Queen Flexible Bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), intraoral periapical x-rays (D0220 and D0230), bitewing x-rays (D0274), prophylaxis (D1110), topical application of fluoride varnish (D1206), and resin-based composite (D2391) provided on May 6, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, bitewing x-rays, prophylaxis, topical application of fluoride varnish, and resin-based composite. You say that you were not advised that this provider had opted out of Medicare in 2021. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds.

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), intraoral periapical x-rays (D0220 and D0230), bitewing x-rays (D0274), prophylaxis (D1110), topical application of fluoride varnish (D1206), and resin-based composite (D2391) provided on May 6, 2021 by a Medicare opt out provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator (POC).

You asked the Plan to pre-approve an Inogen POC. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says they have approved a non-brand specific POC to meet your needs in the home, which provides the same purpose as the requested Inogen POC.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that the Plan has approved a non-brand POC. The non-brand POC serves the same purpose as an Inogen POC. Therefore, we decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator (POC).