Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a disposable continuous glucose monitor (CGM) sensor (A9276).
You asked the Plan to pre-approve the disposable continuous glucose monitor sensor. You say that the sensor is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the DME benefit are defined in CMS Ruling 1682R as therapeutic CGMs. We looked at the file and Medicare rules. The requested item is a disposable sensor and not a therapeutic CGM. The requested code (A9276) is not covered. Based on this information, we decided that Medicare rules for coverage of the disposable continuous glucose monitor sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a disposable continuous glucose monitor (CGM) sensor (A9276).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant care services (S5125).
You asked the Plan to pre-approve the attendant care services. You say that you need a caregiver 7 days a week because you have had 9 seizures throughout the course of one day, and you suffer from memory loss. The Plan denied your request. The Plan says this service is not covered under Medicare.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the attendant care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve attendant care services (S5125).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an extraction (D7210) and adding a tooth to an existing partial denture (D5650) provided on February 4, 2021.
You asked the Plan to pay for an extraction and adding a tooth to an existing partial denture. You say that the provider charged incorrectly. 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 pay for an extraction (D7210) and adding a tooth to an existing partial denture (D5650) provided on February 4, 2021.
Your complaint about the provider charging incorrectly 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis services (90990) provided from January 3, 2021, through February 26, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services provided.
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 outpatient dialysis treatments. You have been asked to pay $874.80 ($364.50 x 20% coinsurance=$72.90 x 12) for the dialysis services provided. 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 the dialysis services (90990) provided from
January 3, 2021, through February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4260), a bone replacement graft (D4263), and biologic materials to aid in soft and osseous tissue regeneration (D4265).
You asked the Plan to pre-approve osseous surgery, a bone replacement graft, and biologic materials to aid in soft and osseous tissue regeneration. You say that the services at issue 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 osseous surgery (D4260), a bone replacement graft (D4263), and biologic materials to aid in soft and osseous tissue regeneration (D4265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751).
You asked the Plan to pre-approve a crown. You say that the services is necessary. The Plan denied your request. The Plan says the service at issue is not a covered 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 a crown (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and root canal to be provided by an endodontist.
You asked the Plan to pre-approve the consultation and root canal. You say that the dentist advised that you need to see an endodontist to perform these services. The Plan denied your request. The Plan says there is no benefit for services to be performed by an endodontist.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a consultation and root canal to be provided by an endodontist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that it is difficult finding a provider during COVID. The Plan denied your request. The Plan says the services are available from 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 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 a referral to an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve physical therapy. You say that patients with neurologic conditions have unique physical therapy needs that are not easily met with general physical therapy. The Plan denied your request. The Plan says that the member agreed to obtain all care from Plan providers at in-Plan facilities unless the care needed is urgent/emergent or is not available from Plan providers. The services being requested are not of an urgent/emergent nature. The Plan does have therapists trained to provide therapy for movement disorders.
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 physical therapy to be provided by the requested out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the trabeculoplasty laser surgery and the drainage of eye provided on April 9, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the trabeculoplasty laser surgery and drainage of eye. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the trabeculoplasty laser surgery and the drainage
of eye provided on April 9, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electro-acupuncture device (L8679).
You asked the Plan to pre-approve the electro-acupuncture device. You say that the device is medically necessary. The Plan denied your request. The Plan says this device is non-covered.
The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices used for stimulation of auricular acupuncture points are non-covered. We looked at the file and Medicare rules. The requested device is not eligible for Medicare coverage. Based on this information, we decided that Medicare rules for coverage of the electro-acupuncture device have not been met. Therefore, we decided that the Plan does not have to pre-approve an electro-acupuncture device (L8679).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier.
You asked the Plan to pre-approve an air purifier. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not primarily and customarily used to serve a medical purpose and is generally useful to a person in the absence of illness or injury.
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 air purifier.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 19.
You asked the Plan to pre-approve the dental service. You say that the crown is medically necessary. The Plan
denied your request. The Plan says the crown is not medically necessary.
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
service when the services are medically necessary and reasonable.
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 dental service. Our reviewer says
that the crown is not medically necessary. Our physician reviewer found there does not appear to be any
recurrent decay or areas of fracture present. The reviewer found that the provided information does not show
extensive breakdown of the tooth and also does not show a current need to replace any existing restorations.
Given that there is minimal missing structure and no cuspal involvement, the reviewer found that the criteria
for crowns has not been met and there is no necessity for the requested crown on tooth #19.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367) provided April 22, 2020, July 31, 2020, and September 9, 2020, and the deep sedation/general anesthesia - first 15 minutes (D9222) and deep sedation/general anesthesia - each subsequent 15-minute increment (D9223) provided June 19, 2020.
You asked the Plan to pay for the cone beam CT scan and deep sedation/general anesthesia. You say that the services were medically necessary and therefore should be covered. The Plan denied your request. The Plan says the cone beam CT scan is not a covered service and the anesthesia was not billed with a covered procedure and therefore is 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. In this case the record does not show that any covered services were billed along with the general anesthesia and therefore the deep sedation/general anesthesia does not meet criteria for coverage. Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT scan is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367) provided April 22, 2020, July 31, 2020, and September 9, 2020, and the deep sedation/general anesthesia - first 15 minutes (D9222) and deep sedation/general anesthesia - each subsequent 15-minute increment (D9223) provided June 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc injections (J7327), 2 units.
You asked the Plan to pre-approve Monovisc. You say that the enrollee has bilateral osteoarthritis of the knee, complaining of moderate to severe pain. You say that the enrollee has had ongoing knee pain despite extensive conservative management. You also say that hyalgan injections were ordered for the left and right knees. The Plan denied your request. The Plan says the requested drug does not meet the criteria for coverage.
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 Monovisc. Our reviewer says that the requested Monovisc injections are not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drugs. The reviewer found that there is no indication in the records that the enrollee received the requested medication in the past 365 days. The reviewer also found that there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc injections (J7327), 2 units.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions (D7410 x10).
You asked the Plan to pre-approve extractions. You say that you want the Plan to cover the services at issue. 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 extractions (D7410 x10).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve dermatology services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network dermatologist.
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 dermatology services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the root canal (D3310) provided on April 21, 2021.
You asked the Plan to pay for the dental service. You say that you were referred to this provider. You also say that you were not aware that the provider did not participate with the plan. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network 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 out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the root canal (D3310) provided on April 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided from February 20, 2020, to March 7, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you did not request a private room. You say the private room was the only one available after surgery. 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 $200 copayment per day, days 1-7 for Medicare-covered hospital stays.
You have been asked to pay a $200 copayment for each day, for days 1-7 of the inpatient hospital stay. ($200 x 7 = $1,400). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows the cost-sharing amount is the same for a semi-private room and a private room.
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 inpatient hospital admission provided from February 20, 2020, to March 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided November 6, 2020.
You asked the Plan to pay for the comprehensive oral exam. You say that you would like the services covered. The Plan denied your request. The Plan says this service was previously covered in April 2019, and you were not yet eligible for coverage at the time of 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.
The Plan covers the comprehensive oral exam once every three years. We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was previously covered on April 3, 2019. Based on this information, we determined that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided November 6, 2020.