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

We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete mandibular denture. You say that you accidentally lost your
bottom denture and now only have a top denture that you can wear. The Plan denied your request. The Plan
says this service exceeds the maximum count allowed per period.
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, complete mandibular dentures (D5120)
are limited to one procedure every five plan years. The record shows that you received a complete mandibular
dentures (D5120) on February 28, 2018 and your complete mandibular dentures benefit has been exhausted.
Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture (D5120).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for a preventive medicine exam (99387) provided on October 8, 2019.
You asked the Plan to hold you harmless for the exam. You say that this service was part of the initial exam, not something you specifically requested. The Plan denied your request. The Plan says that the preventive medical exam is a non-covered benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. You were referred for the exam by your physician. The physician is a contract provider. The file does not show that the plan provided notice that the exam would not be covered. Under Medicare rules, this means the exam is considered approved by the plan. Therefore, we decided that the Plan has to hold you harmless for a preventive medicine exam (99387) provided on October 8, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a Euflexxa 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 that it's preferred viscosupplements are Orthovisc and Monovisc and don't require prior authorization.
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 medically reasonable and necessary. Our physician reviewer found the enrollee has tried and failed the first step of therapy. He had a trial of Monovisc, and had a reaction. The requested injection is medically reasonable and 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 the injection have been met. Therefore, we decided that the Plan has to pre-approve a Euflexxa injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve visual field assessment, with real time analysis (0379T).
You asked the Plan to pre-approve the special eye test. You say that this service is not only medically
necessary for the enrollee based on the attached medical records, but it is also a service that is covered by
Medicare and many other health insurers. The Plan denied your request. The Plan says this service is not
covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the special eye test have not been met. Therefore, we decided that the Plan does not have to preapprove
visual field assessment, with real time analysis (0379T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three retainer crowns (D6740 x3) and two pontics (D6245 x2).
You asked the Plan to pre-approve the retainer crowns and pontics. You say that the enrollee has tooth decay that causes teeth to weaken and jeopardizes teeth structure. You also say that the tooth decay has reached serious levels. The Plan denied your request. The Plan says these services 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 three retainer crowns (D6740 x3) and two pontics (D6245 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SoClean CPAP cleaner
You asked the Plan to pre-approve this item. You say that the enrollee suffers from chronic respiratory
infections and it is medically necessary for the enrollee to receive the device to maintain proper hygiene of the
CPAP device. The Plan denied your request. The Plan says that the cleaning machine is considered hygienic
supply, not primarily medical in nature and not covered by Medicare.
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. Therefore, we
decided that the Plan does not have to pre-approve a SoClean CPAP cleaner.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the requested physician's services. You say that you go to this doctor every year. You say he is one of the world's best doctors and he also went to the same school as your cousin. The Plan denied your request. The Plan says out of network services are not approved unless they are not available in network or are emergent.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic pill box (E1399).
You asked the Plan to pre-approve an electronic pill box. You say that you feel that this should be covered. The Plan denied your request. The Plan says this item is not covered under Medicare or the Plan.
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 an electronic pill box (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on January 22,
2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you should only be responsible
for the difference between a regular evaluation and a comprehensive evaluation. The Plan denied your request.
The Plan says your maximum benefit has been met for this service. The Plan also says that you received a
comprehensive oral exam less than 36 months ago.
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, comprehensive oral exams are limited
to one every 36 months. The record shows that you received a comprehensive oral exam on March 12, 2018
and your comprehensive oral exams benefit has been exhausted. Therefore, we decided that the Plan does not
have to pay for the comprehensive oral evaluation provided on January 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay from
September 20, 2019 to October 17, 2019.
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the charges because
you were told that your stay would be fully covered. The Plan denied your request. The Plan says the claims
were processed correctly and you are being charged the correct 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 $0
copayment per day for days 1-20 and a $160 copayment for days 21-100 for SNF care.
You had a SNF stay from September 20, 2019 to October 17, 2019. You are not being charged a copayment for
days 1-20 (September 20, 2019 to October 9, 2019). You are responsible to pay a $160 copayment for days 21-
27 (October 10, 2019 to October 16, 2019). $160 (copayment) x 7 (SNF days) = $1,120.
You have been asked to pay the total copayment amount of $1,120 for a SNF stay. A SNF stay falls within the
SNF care 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 a skilled nursing facility
(SNF) stay from September 20, 2019 to October 17, 2019.
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 need these for your daily health. 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 the MyoPro MotionG prosthetic device (L8702) to be
provided by an out of network (OON) provider.
You asked the Plan to pre-approve the prosthetic device. You say that the device is medically necessary. The
Plan denied your request. The Plan says comparable items are available in-network and would be covered.
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 MyoPro MotionG prosthetic device (L8702) to be provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient mental health services (90838) to be
provided by an out of network (OON) provider.
You asked the Plan to pre-approve the outpatient mental health services. You say that the services are
medically necessary. The Plan denied your request. The Plan says there are network providers available.
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 outpatient mental health services (90838) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 27, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 service 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 January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the health club membership services to be provided by
an out of network (OON) provider.
You asked the Plan to pre-approve the health club membership. You say that this service is cheaper than the
network provider and medically necessary. The Plan denied your request. The Plan says there are no out-of network
benefits for health club memberships.
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 health club membership services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on January 2,
2020.
You asked the Plan to waive the copayment for the laboratory work. You say that your laboratory work should
be 100% covered and that you have never had to pay a copayment before. The Plan denied your request. The
Plan says you have been charged 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 $30
copayment for Medicare-covered lab services and diagnostic procedures/tests performed in an in-network
outpatient hospital facility.
You have been asked to pay a $30 copayment for the laboratory work. The laboratory work falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" 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 laboratory work provided on January 2, 2020.
Your complaint that there are no independent labs in your area 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes A7030 and A7031 provided on October 19, 2019.
You asked the Plan to pay for CPT codes A7030 and A7031. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for CPT codes A7030 and A7031 provided on October 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's
current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may
benefit from additional multiple therapies, however the enrollee's functional level as well as confusion with
inconsistency at times in therapy does not support that she requires therapy to be in an IRF with an intensive
level program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four endodontic therapies (D3310 x4) and four core
buildups, including any pins when required (D2950 x4).
You asked the Plan to pre-approve endodontic therapies and core buildups. You say that you have needed
dental work for two years and you think it is entirely covered by your plan. The Plan denied your request. The
Plan says these services are not covered by the 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 pre-approve four
endodontic therapies (D3310 x4) and four core buildups, including any pins when required (D2950 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) rendered by the
out of network (OON) provider October 15, 2019 and October 21, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were provided by an out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the services at issue in this appeal. 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 the subsequent nursing facility care (99310) rendered by the out of network (OON)
provider October 15, 2019 and October 21, 2019.
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 this is medically necessary. The Plan denied your request. The Plan says that this is not covered by Medicare.
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.