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

We decided that the Plan does not have to pre-approve endodontic therapy (D0330, a crown (D2740) and a core buildup (D2950).
You asked the Plan to pre-approve the dental services. You say that this dental work is necessary. You want to know if there is any way the Plan can cover these services. The Plan denied your request. The Plan says these services are not covered by your dental 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 endodontic therapy (D0330, a crown (D2740) and a core buildup (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto, 20 mg tablet.
You asked the Plan to pre-approve Xarelto. You say that the enrollee has tried Coumadin in the past. You say that it is not a good option for him. You also say that the enrollee has done well with Xarelto. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.
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 Xarelto, 20 mg tablet.
Benefits for Xarelto 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) and treatment of a root canal obstruction (D3331).
You asked the Plan to pre-approve the dental services. You say that you need these services to complete the work. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan also says that treatment of a root canal obstruction 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 core build up and treatment of a root canal obstruction are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) and treatment of a root canal obstruction (D3331).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laboratory services while out of the Plan's service area.
You asked the Plan to pre-approve laboratory services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested service is not deemed urgent, emergent or unforeseen and is available within your medical group.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. The file shows that requested laboratory services are neither emergent nor urgent and are not being requested due to an unforeseen illness or condition. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pre-approve laboratory services while out of the Plan's service area.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two alveoloplasty procedures (D7311) and drug injections (D9610).
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by the Plan's dental 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 two alveoloplasty procedures (D7311) and drug injections (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete denture - maxillary (D5110) and the complete denture - mandibular (D5120) received July 29, 2020.
You asked the Plan to pay for the dentures. You say that your dentures were loose and 25 years old. 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 pay for the complete denture - maxillary (D5110) and the complete denture - mandibular (D5120) received July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5212).
You asked the Plan to pre-approve the denture. You say that you had additional teeth removed and this denture is necessary. The Plan denied your request. The Plan says this item is not covered by your dental 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 partial upper denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain crowns (D2740) and core build up (D2950) for teeth # 20 and 21.
You asked the Plan to pre-approve the dental services. You say that the crowns and core build up are medically necessary. The Plan denied your request. The Plan says crowns and core build up are covered once per tooth every 5 plan years. The Plan also says that the frequency limit for these services have 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 crowns and core build up are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a crown and core build up for tooth # 20 that you received on May 18, 2020. The record shows that the Plan paid for a crown and
core build up for tooth # 21 that you received on November 5, 2018. Therefore, we decided that the Plan does not have to pre-approve porcelain crowns (D2740) and core build up (D2950) for teeth # 20 and 21.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 25, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you thought the provider was in-network because you paid your $25 copayment at the time of the visit. 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 office visit provided on March 25, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 20.
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 porcelain 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 porcelain crown (D2740) for tooth # 20.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery backup for a continuous positive airway pressure (CPAP) machine.
You asked the Plan to pre-approve a batter back up. You say that you have problems with power outages and fear your health is at risk. The Plan denied your request. The Plan says the item is a non-covered benefit, as it does not serve any medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a battery backup for a continuous positive airway pressure (CPAP) machine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 9, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says this provider prescribed the orthoses without a face-to-face evaluation, physical examination or imaging demonstrating medical necessity.
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 pay for the lumbar-sacral orthosis (L0650). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair seat cushion (E2601) for use with transport chair.
You asked the Plan to pre-approve wheelchair seat cushion. You say that you are requesting an appeal. Pleas process your appeal request. The Plan denied your request. The Plan says a seat cushion is not covered when being used with a transport chair.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that if the beneficiary does not have a covered wheelchair, then the cushion will be denied as not reasonable and necessary. We looked the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wheelchair seat cushion have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair seat cushion (E2601) for use with transport chair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement of the copayment for the transthoracic echocardiography (93306) provided on January 14, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $165 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic) .
You have been asked to pay a $165 copayment for the Medicare-covered radiological diagnostic service 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 issue reimbursement of the copayment for the transthoracic echocardiography (93306) provided on January 14, 2021.
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 need this item. The Plan denied your request. The Plan says this item is a non-covered benefit as it is considered a convenience item and not primarily medical in nature.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says that the enrollee has not tried and failed zoledronic acid. The Plan also says that there is no indication zoledronic acid, an IV bisphosphonate drug, would likely be less effective, and/or cause adverse effects for the enrollee.
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 Prolia. Our reviewer says that Prolia is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the preferred drug. The reviewer also found that the provided documentation does not indicate that the plan's required drug 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
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. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says incontinence supplies are not covered by Medicare or the Plan.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided on February 25, 2021 by an out of network (OON) provider.
You asked the Plan to pay for drug testing services. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not 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 had network providers available who could have provided the items/services at issue in this appeal. 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 drug testing services provided on February 25, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3330) for tooth # 15 to be provided by an out of network provider.
You asked the Plan to pre-approve the dental service. You say that you had your knees replaced and cannot get an infection in your tooth. You say that you are on amoxicillin right now. You also say that you have an appointment for a root canal on June 14, 2021. The Plan denied your request. The Plan says endodontics are not covered. The Plan also says that 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, endodontic services, including the requested root canal are not among those covered under this benefit. Additionally, dental services performed out of network are not covered either. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3330) for tooth # 15 to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and the palliative (emergency) treatment of dental pain (D9110) received February 22, 2021.
You asked the Plan to pay for the limited oral evaluation and the palliative treatment of dental pain. You say that you had a broken tooth and it needed to be repaired. The Plan denied your request. The Plan says the requested services are 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 pay for the limited oral evaluation - problem focused (D0140) and the palliative (emergency) treatment of dental pain (D9110) received February 22, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99203, 99213) to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are an in-network providers available to render the requested services.
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 office visits (99203, 99213) to be rendered by the out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the hospital observation services (G0378) provided on September 15, 2020 and September 24, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have 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 $225 copayment for outpatient hospital observation services. You have been asked to pay $450 ($225 copayment x 2 days) for the outpatient hospital observation 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 copayments for the hospital observation services (G0378)
provided on September 15, 2020 and September 24, 2020.