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

We decided that the Plan does not have to pay for the hearing aids (V5260) purchased on March 5, 2021, from an out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that you did not know that you needed to see a provider in a specific network to obtain covered hearing aids. You also said that you have tried returning these hearing aids to purchase them from the correct provider network, but the provider is refusing to take them back. The Plan denied your request. The Plan says these hearing aids were purchased from a provider who does not participate in the Plan's routine hearing network. Therefore, payment cannot be made.
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 they are purchased from a provider in the Plan's specified routine hearing vendor network.
We looked at the file and the Plan's rules. The hearing aids were purchased from a non-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 (V5260) purchased on March 5, 2021, from an out-of-network provider.
Your complaint about potential missing information from the Plan or a potential misunderstanding with the provider 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right total knee arthroplasty.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation of a failed home exercise program or physical therapy.
The Plan must follow Medicare rules. Medicare rules say that total knee arthroplasty can be covered if the LCD criteria have been 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. You are being treated for osteoarthritis of the knee. Detailed documentation is not evident regarding previous osteotomy failure, distal femur fracture, malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues, failure of previous unicompartmental knee replacement, avascular necrosis of the knee, or proximal tibia fracture. X-rays demonstrated osteoarthritis of the knee, with likely joint body or other abnormality posteriorly. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures including physical therapy and home exercises (flexibility and muscle strengthening exercises). Detailed documentation is not evident regarding functional limitations or inability to perform her activities of daily living. Our physician reviewer found that your condition does not meet Medicare criteria for total knee arthroplasty. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve right total knee arthroplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevation feature (E2300) for the enrollee.
You asked the Plan to pre-approve the feature. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 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 seat elevation feature (E2300) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
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 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 a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), oral hygiene instructions (D1330), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided April 29, 2020.
You asked the Plan to pay for the panoramic x-rays, oral hygiene instructions, and intraoral x-rays. You say that you tried to refuse the panoramic x-ray but were told it was necessary. You cannot afford the cost of the services. The Plan denied your request. The Plan says you have exceeded frequency limits for the panoramic x-rays and the remaining services are not covered under your benefits.
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 panoramic x-rays once every three years.
We looked at the file and Medicare rules. The Plan provided documentation showing that panoramic x-rays were previously covered on July 1, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of the panoramic x-rays has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the oral hygiene instructions and intraoral x-rays are not among those benefits. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330), oral hygiene instructions (D1330), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided April 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3 simple extractions (D7140), the surgical extraction
(D7210), the 3 bone replacement grafts (D7953), and the deep sedation (D9222) provided on January 21, 2021.
You asked the Plan to pay for the dental services. You say that your dental plan advised that the bone
replacement graft procedure was a medical service. You say that you believe that the services were medically
necessary. You also say that you feel the services should be covered. The Plan denied your request. The Plan
says the services you received were dental in nature, not medical. The Plan says that these services are not
covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the 3 simple extractions (D7140),
the surgical extraction (D7210), the 3 bone replacement grafts (D7953), and the deep sedation (D9222)
provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on October 1, 
2019. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says there were insufficient medical records submitted to support this claim. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provided medical records that support the 
services billed. In this case, insufficient medical records have been provided to support the services billed on 
the claim. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services provided to the enrollee on October 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for astigmatism correcting intraocular lenses (V2799) provided
on May 26, 2021.
You asked the Plan to pay for astigmatism correcting lenses. You say that you have no vision in your right eye
due to a birth defect. You also say the provider felt this lens was the highest and best chance of enhanced vision
on your left eye and to prevent further damage. The Plan denied your request. The Plan says this service is not
a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a
conventional IOL.
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatismcorrecting
feature of an IOL. Therefore, we decided that the Plan does not have to pay for astigmatism
correcting intraocular lenses (V2799) provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (J3490, J3411, J3415, J1955) provided on September 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not supported.
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of codes J3490, J3411, J3415, and J1955, is not supported by the records provided. Our reviewer found that the documentation supports "pre-filled syringe containing nutria-pharmaceutical blend/mix" was used for injections. Therefore, codes J3490, J3411, J3415 and J1955 should not be separately reported.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (J3490, J3411, J3415, J1955) provided on September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the labial veneer (D2960) provided on March 24, 2021.
You asked the Plan to pay for the dental service. You say that you went to the dentist for a chipped tooth. You say that the provider did not mention veneer resin for the tooth. You also say that if you had known how much you would have to pay, you would not have had the service. The Plan denied your request. The Plan says labial veneer is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the labial veneer is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the labial veneer (D2960) provided on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a chair lift purchased on March 6, 2021. 
 
You asked the Plan to pay for this item. You say that the Plan should pay for this lift chair as it was medically 
necessary. The Plan denied your request. The Plan says you did not have prior authorization to purchase this 
equipment and the retailer you purchased it from is not a Medicare eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided by a physician or practitioner who is not a Medicare eligible provider. The Plan 
contract specifically states durable medical equipment over $1000 requires prior authorization. You did not 
have prior authorization to purchase this equipment. The retailer you purchased the item from is not a Medicare 
eligible provider. Therefore, we decided that the Plan does not have to pay for a chair lift purchased on March 
6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuroplasty and/or transposition (64716) provided January 26, 2021.
You asked the Plan to pay for the surgery services. You say that this was a medically necessary procure. Without the performed procedure, the enrollee was at risk for orbital infection and for permanent enophthalmos, vertical orbital dystopia, diplopia and ocular pain. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 64716 is neuroplasty and/or transposition of a cranial nerve. We find that CPT code 64716 is not supported in the medical record. Specifically, the operative report did not include documentation of neuroplasty and/or transposition of a cranial nerve. Based on this information, we decided that Medicare rules for coverage of the surgery services have not been met. Therefore, we decided that the Plan does not have to pay for neuroplasty and/or transposition (64716) provided January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on March 15, 2021.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that this was a semi-annual exam and teeth cleaning which you paid out of pocket. You say that the benefits indicate this would be covered up to $700 annually and you assumed you would be reimbursed. The Plan denied your request. The Plan says payment cannot be issued for services performed by providers who have opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for the pneumatic compression device coded E0652 have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee's lymphedema
extends onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7321) provided August 11, 2020.
You asked the Plan to pay for the alveoloplasty. You say that you were not told you were be charged for the services and if you had you would have refused the service. The Plan denied your request. The Plan says this service is not covered under your benefits. Your other concerns are being reviewed separately.
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 alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant (D7321) provided August 11, 2020.
Your complaint about not being informed by the provider that the service is not covered prior to the work being performed 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (32557) provided on April 17, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says only one unit of this code is supported.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The records provided show that only one unit of code 32557 was provided on the date of service in question, which was previously processed and paid by the Plan. An additional unit of this code is not supported.
Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (32557) provided on April 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that this is medically necessary. The Plan
denied your request. The Plan says that they made multiple attempts to obtain clinical notes and a physician
order from the doctor, but they did not receive them.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must corroborate the
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have
been met.
We looked at the file and Medicare rules. Specifically, medical records were not provided for review in this
case. The record shows that the Plan made multiple attempts to secure medical records, without success.
Without medical records, we cannot determine if Medicare criteria are met in this case. Based on this
information, we decided that Medicare rules for coverage of a power wheelchair have not been met. Therefore,
we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), bifocal lenses (V2200) and a miscellaneous vision item/service (V2799) provided on April 2, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for eyeglass frames, bifocal lenses and a miscellaneous item. You say that you were not advised that the provider you saw for eyeglasses was not in network. You also say that you were advised to submit a reimbursement form. You would like to be reimbursed for this service. The Plan denied your request. The Plan says you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.
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. Routine vision services are offered through the Plan. Services are only covered when received by a participating provider. The records provided for review do not show that the services at issue were urgent or emergent. 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 eyeglass frames (V2020), bifocal lenses (V2200) and a miscellaneous vision item/service (V2799) provided on April 2, 2021, by an out-of-network (OON) provider.