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

We decided that the Plan does not have to pay for the dental services (D7286, D4266, D3430, D3426, D3421) received January 26, 2021.
You asked the Plan to pay for the dental service (D7286, D4266, D3430, D3426, D3421). You say that you would like the Plan to cover the requested services under either your dental or medical benefit. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit. The provider submitted office records and stated they do not convert dental codes to medical CPT codes, nor do they bill medical insurance.
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 dental services (D7286, D4266, D3430, D3426, D3421) received January 26, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facility fee provided on March 15,
2021.
You asked the Plan to waive the copayment for the facility fee. You say that you have to go to the hospital for
the injection. You say you cannot afford the $325 copayment. The Plan denied your request. The Plan says you
have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325
copayment for each Medicare-covered outpatient hospital visit or hospital outpatient surgical facility visit.
You have been asked to pay a $325 copayment for the facility fee. The facility fee falls within the "Outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the facility fee provided on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you always get the inserts with no issues for your flat feet. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150) and the extraction (D7210) with the oral surgeon.
You asked the Plan to pre-approve the dental services. You say that you were referred to an oral surgeon by your cardiologist. The Plan denied your request. The Plan says services must be performed by a participating general dentist.
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 dental services when the services are performed by a general dentist. We looked at the file, and Medicare rules. The Plan only covers the requested services when they are performed by a general dentist. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150) and the extraction (D7210) with the oral surgeon
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown - porcelain fused to predominantly base metal (D2751).
You asked the Plan to pre-approve the crown. You say that you want to save your only tooth remaining that needs any major work. The Plan denied your request. The Plan says the requested service is only covered once per tooth every 60 months.
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 crowns, one procedure per tooth. We looked at the file, and Medicare rules. The Plan contract states that crowns are covered one procedure per tooth, every five plan years. The Plan has submitted evidence that you last received a crown on this tooth on December 4, 2018. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve the crown - porcelain fused to predominantly base metal (D2751).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are having left heel pain that prevented you
from doing regular exercises and wants to prevent further health problems in the future. The Plan denied your
request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and 2 extractions to be performed by an oral surgeon.
You asked the Plan to pre-approve the dental services. You say that you were told by your dentist that you need to have your teeth extracted by an oral surgeon. You say that you had a bad reaction to the antibiotics used last time. You also say that The Plan denied your request. The Plan says dental services must be performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon 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, dental services performed by an oral surgeon are not among those covered under this benefit. The Evidence of Coverage clearly states that services must be performed by a general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation and 2 extractions to be performed by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of impacted tooth - partially bony (D7230).
You asked the Plan to pre-approve the removal of impacted tooth. You say that your entire mouth is in pain due to the wisdom teeth. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.
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 removal of impacted tooth - partially bony (D7230).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740), a core buildup (D2950), and retreatment of previous root canal therapy (D3348).
You asked the Plan to pre-approve a crown, a core buildup, and retreatment of previous root canal therapy. You say that the services are necessary because you can't eat. 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 a crown (D2740), a core buildup (D2950), and retreatment of previous root canal therapy (D3348).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided at the in-network benefit level.
You asked the Plan to pre-approve physical therapy services to be provided at the in-network benefit level. You say that you are the only provider in the area that has the licensures and experience and does the treatment types that the enrollee was prescribed by her doctor in late 2020. The Plan denied your request. The Plan says the enrollee's Medicare Advantage Plan features a large network of health care providers, including primary care. The plan also provides coverage for out-of-network physicians and practitioners at 60% of the Medicare allowable rate. There are providers within the Health Plan network that can address the enrollee's symptoms.
The contract with the Plan allows for coverage with out-of-network physicians and practitioners at 60% of the Medicare allowable rate.
We looked at the file and Medicare rules. The file shows that there are providers within the health Plan network that can address the enrollee's symptoms. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided at the in-network benefit level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee prosthetics to be provided by an out-of-network provider.
You asked the Plan to pre-approve the knee prosthetics. You say that you have been servicing this patient in his home and provided the previous prosthesis in 2020. You say that this would be a huge change for the patient and you would like to continue his care. The Plan denied your request. The Plan says the service can safely be given by an in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. 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 the knee prosthetics to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Premarin.
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 Premarin.
Benefits for these services 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 a shower chair.
You asked the Plan to pre-approve a shower chair. You say that your doctor prescribed this for you. 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 surgical placement of implant (D6010), custom fabricated abutment (D6057), and abutment supported porcelain fused to metal crown (D6059).
You asked the Plan to pre-approve surgical placement of implant, custom fabricated abutment, and abutment supported porcelain fused to metal crown. You say that the services are medically necessary. The Plan denied your request. The Plan says the services at issue are not covered services.
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), custom fabricated abutment (D6057), and abutment supported
porcelain fused to metal crown (D6059).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide non-emergency transportation.
You asked the Plan to provide the non-emergency transportation. You say that driving on the thruway gives you anxiety and you need to travel via the thruway to reach your appointment. The Plan denied your request. The Plan says non-emergent transportation such as wheelchair van, taxi, stretcher van or ambulette are not covered.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file, and Medicare rules. The Plan does not cover non-emergent transportation such as wheelchair van, taxi, stretcher van, or ambulette rides. Based on this information, we decided that Medicare rules for coverage of the non-emergency transportation have not been met. Therefore, we decided that the Plan does not have to provide non-emergency transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft, initial site, (D4263), biologic materials to aid in soft and osseous tissue regeneration (D4265), osseous surgery (D4260), and a bone replacement graft, each additional site, (D4264 x 3).
You asked the Plan to pre-approve the dental services. You say that you are having problems with your gums and teeth. You say that if you do not do the surgery, you will lose your teeth. You also say that you are scheduled for surgery. The Plan denied your request. The Plan says the services are not listed as covered. The Plan also says that you are not enrolled in the optional supplemental dental rider.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve 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 pre-approve a bone replacement
graft, initial site, (D4263), biologic materials to aid in soft and osseous tissue regeneration (D4265), osseous
surgery (D4260), and a bone replacement graft, each additional site, (D4264 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740) provided on April 7, 2021.
You asked the Plan to pay for a crown. You say that the service was medically necessary. The Plan denied your request. The Plan says the service at issue is a covered benefit, however the $225 quarterly benefit maximum had already been met.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown have not been met. Specifically, the record shows that you had exhausted your quarterly dental benefit maximum. Therefore, we decided that the Plan does not have to pay for a crown (D2740) provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6750 x2), and pontic (D6250).
You asked the Plan to pre-approve retainer crowns, and pontic. You say that the services at issue are necessary. You do not want a removable bridge where you will be taking it out, cleaning, and putting it back. 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 retainer crowns (D6750 x2), and pontic (D6250).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hyalgan injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says Part B step therapy criteria are not met.
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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. Orthovisc was requested and approved on July 9, 2021. however, there is no documentation related to this medication. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Hyalgan is not approved as step criteria have not been met. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Hyalgan injection for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you've been experiencing increased pain in the insteps of both feet and big toe joints from bunions. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
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 you have lower back pain, unsteadiness feet
and not able to stand for too long. 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 the mandibular and maxillary partial dentures (D5213, D5214).
You asked the Plan to pre-approve the mandibular and maxillary dentures. You say that the last dentures you received do not fit well. The Plan denied your request. The Plan says partial dentures are only covered once every 96 months.
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 mandibular and maxillary partial dentures once every 96 months. We looked at the file, and Medicare rules. The Plan covers partial dentures once every 96 months. The Plan has submitted evidence that partial dentures were last covered by the Plan on October 29, 2019. Based on this information, we decided that the Plan's rules for coverage of the mandibular and maxillary dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve the mandibular and maxillary partial dentures (D5213, D5214).
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 the additional routine transportation trips. The Plan denied your request. The Plan says that the Plan allows for 40 one-way trips per Plan year. Additional trips are not covered.
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 offers 40 one-
way routine transportation trips per Plan year. Additional trips are not covered. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.