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

We decided that the Plan does not have to pre-approve the endodontic therapy, premolar tooth (D3320).
You asked the Plan to pre-approve the endodontic therapy. You say that the endodontic therapy is necessary. The Plan denied your request. The Plan says endodontics 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 the endodontic therapy, premolar tooth (D3320).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX.
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 the services are not medically necessary.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She
has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not support that the
required drugs would be contraindicated or less effective; therefore, Supartz FX is not reasonable or medically
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Supartz FX
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health services.
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
The file shows that 8 home health nursing, physical therapy, and occupational therapy visits were requested.
The Plan has agreed to pre-approve 4 visits of each. 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 home health services. Our physician reviewer found that you are at a supervision assist level for
sitting up, standing and walking using a rolling walker. You do not have documented skilled nursing needs.
You do not have documented skilled therapy needs. As such, the additional services are not shown to be
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 home health services have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional home health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyzine hydrochloride 25mg tablets.
You asked the Plan to pre-approve Hydroxyzine hydrochloride. You say that Hydroxyzine hydrochloride 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 Hydroxyzine hydrochloride 25mg tablets.
Benefits for Hydroxyzine hydrochloride 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 incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown (D6740).
You asked the Plan to pre-approve the dental service. You say that you are having difficulty chewing. You say that your chewing teeth were removed. You also say that you need the bridge work to be approved so that you can eat properly. The Plan denied your request. The Plan says retainer crown 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a retainer crown (D6740).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide a CGM system.
You asked the Plan to provide a CGM system. You say that the enrollee has complicated medical issues and needs a CGM to help with control. The Plan denied your request. The Plan says documentation does not show the enrollee is testing more than four times a day or is using insulin by three or more injections per day with frequent dose adjustments.
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 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
system have not been met. Therefore, we decided that the Plan does not have to provide a CGM.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 18, 2021.
You asked the Plan to pay for the limited exam. You say that this service was urgent and medically necessary, and therefore should be covered. The Plan denied your request. The Plan says this service can only be covered once per year. You previously had a limited oral exam in January 2021, which was paid for by the Plan. Therefore, payment cannot be made for this 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 limited exam is requested in a frequency that is not covered under this benefit. Documentation shows that you have already had a limited oral evaluation in 2021 which was covered by the Plan. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).
You asked the Plan to pre-approve the dental item. You say that you need this denture. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.
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 partial upper denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a partial upper denture that you received on January 31, 2017. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant (D6010), a custom fabricated abutment (D6057), an implant (D6065), a surgical stent (D5982), and a cone beam computed tomography scan (D0366).
You asked the Plan to pre-approve surgical placement of implant, a custom fabricated abutment, an implant, a surgical stent, and a cone beam computed tomography scan. You say that you thought these services would be covered. The Plan denied your request. The Plan says the services at issue are not covered 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. 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 surgical placement of implant (D6010), a custom fabricated abutment (D6057), an implant (D6065), a surgical stent (D5982), and a cone beam computed tomography scan (D0366).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5211).
You asked the Plan to pre-approve the dental item. You say that when you eat food, it cuts your gums. You also say that this is beginning to worry you. The Plan denied your request. The Plan says dentures are excluded from coverage.
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 partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5211).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says the Plan covers 24 one-way trips per calendar year and the 25th trip and beyond is not a covered benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. The file shows that the Plan coves 24 one-
way trips per calendar year and the 25th trip and beyond is not a covered benefit.Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal framework with resin denture bases (D5214).
You asked the Plan to pre-approve a partial lower denture. You say that your dentures fell in the toilet and you need new ones. The Plan denied your request. The Plan says this service is only covered once every 5 years and you are not yet eligible for new dentures.
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 a partial lower denture once every five plan years. We looked at the file and Medicare rules. The Plan provided documentation showing that partial lower dentures were previously covered on September 23, 2020. Based on this information, we determined that you are not yet eligible for coverage of new partial lower dentures. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal framework with resin denture bases (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that your husband is unable to get into the bathtub without this equipment. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
You asked the Plan to pre-approve the dental items. You say that your dentures would fall out of your mouth while you were talking. You say that you went back for many adjustments. You say that when they were adjusted, they came back bigger than they were initially. You say that now those dentures are worthless to you. You also say that you were told not to go back to the provider who made your previous set of dentures. The Plan denied your request. The Plan says dentures are covered once every 5 years. 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 dentures (prosthodontics) are
covered, the frequency limit has been reached. The record shows that the Plan paid for dentures that you received on February 3, 2021. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for prosthetic devices provided by a participating provider on March 16, 2021.
You asked the Plan to waive the coinsurance for prosthetic devices. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 20% coinsurance for prosthetic devices and related supplies/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for prosthetic devices. The total allowed amount is $306.79. The total amount you are being asked to pay is $61.36 ($306.79 x 20 % = $61.36). Prosthetic devices fall within the prosthetic devices and related supplies/in-network 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 prosthetic devices provided by a participating provider on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213), and a partial lower denture (D5214).
You asked the Plan to pre-approve the dental services. You say that these are medically necessary. You say that you cannot eat or chew food. You say that you tried to have them adjusted but it did not help. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been reached.
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 partial dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for partial dentures that you received on February 6, 2020. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213), and a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of an implant (D6010), a custom fabricated abutment (D6057), and an abutment supported crown (D6059).
You asked the Plan to pre-approve the dental services. You say that your teeth have deteriorated due to recent medical issues. You also say that now you are finding out that you do not have coverage for the dental services. The Plan denied your request. The Plan says surgical placement of an implant is not listed as a covered service. The Plan says that custom fabricated abutment is not listed as a covered service. The Plan also says that abutment supported crown is not listed as a covered service either.
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
surgical placement of an implant (D6010), a custom fabricated abutment (D6057), and an abutment supported
crown (D6059).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on January 15, 2021.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this copayment. You say that you should only have to pay for an office visit. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $280 copayment for outpatient surgery/in-network. You have been asked to pay a $280 copayment for an outpatient surgery. The injection that was provided is considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls
within the outpatient surgery/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an initial 15 minutes of deep sedation (D9222), an additional 15 minutes of deep sedation (D9223), therapeutic parenteral drugs (D9630), and an extraction (D7210).
You asked the Plan to pre-approve the anesthesia. You say that you need these services. The Plan denied your request. The Plan says anesthesia services are not listed as 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 anesthesia services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an initial 15
minutes of deep sedation (D9222), an additional 15 minutes of deep sedation (D9223), therapeutic parenteral drugs (D9630), and an extraction (D7210).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 4, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 physician's services. 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 physician's services provided on January 4, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 16, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 physician's services provided on February 16, 2021.