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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and the comprehensive periodontal evaluation (D0180) provided on February 22, 2021.
You asked the Plan to pay for the dental services. You say that you were advised that this dentist was in network. You say that you were advised you were covered for 2 cleanings per year. You say that the last exam that you had was 2 years ago when you lived in a different state. You also say that these services should be covered in full. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that the frequency limit has been exceeded. The Plan also says that comprehensive periodontal evaluation 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 and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for this service that you received on July 11, 2019. The comprehensive periodontal evaluation is not among those covered under this benefit. Additionally, the record shows that the calls that were made to the Plan prior to your appointment were not related to dental services. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and the comprehensive periodontal evaluation (D0180) provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the out-of-network dental services you received on January 13, 2021.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says out-of-network services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit when provided by an out-of-network provider. The Plan contract clearly states that you must pay 100% of the cost for out-of-network dental services. Therefore, we decided that the Plan does not have to pay for the out-of-network dental services you received on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement Rollator walker.
You asked the Plan to pre-approve these services. You say that your current walker is broken. The Plan denied
your request. The Plan says the replacement is not covered.
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment (DME) is not
replaced during the reasonable lifetime period of the equipment.
We looked at the file and Medicare rules. The file shows that your current walker is not more than five years
old and cannot be replaced. Based on this information, we decided that Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement
Rollator walker.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 6, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you had no idea you would be seeing a nurse practitioner. You say that the office was informed they made a mistake, but you are still being charged. The Plan denied your request. The Plan says the copayment applied correctly.
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 $40 copayment for each specialist office visit for Medicare-covered services.
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show you were seen in a specialist's office. 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 office visit provided on January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sensor (A9276) and transmitter (A9277) for use with
an interstitial continuous glucose monitoring system.

You asked the Plan to pre-approve a sensor (A9276) and transmitter (A9277). You say that you would like the
Plan to reconsider their denial. The Plan denied your request. The Plan says the requested codes A9276 and
A9277 are not covered under Medicare or the Plan for the items requested.

The Plan must follow Medicare rules. Medicare rules say that a sensor described by code A9276 and a
transmitter described by code A9277 are for use with a non-therapeutic CGM.

We looked at the file and Medicare rules. The services at issue are a disposable sensor described by A9276 and
a transmitter described by code A9277. These items are for a non-therapeutic CGM and are not covered by
Medicare. Based on this information, we decided that Medicare rules for coverage of a sensor (A9276) and
transmitter (A9277) have not been met. Therefore, we decided that the Plan does not have to pre-approve a
sensor (A9276) and transmitter (A9277) for use with an interstitial continuous glucose monitoring system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a folding wheelchair ramp.
You asked the Plan to pre-approve a folding wheelchair ramp. You say that the requested item is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment
have not been met.
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 folding wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided on October 3, 2020.
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not support the items billed.
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 does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the submitted medical records indicate the billed item was provided by a health care provider other than the billing health care provider. In addition, the itemized shipping/billing invoice or proof of delivery does not indicate the name of the servicing provider. The record shows that the Plan made several attempts to obtain
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator provided on October 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Sensor
You asked the Plan to pre-approve Freestyle Libre 14 Day Sensor. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records provided does not show that the enrollee meets the criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre 14 Day Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on January 5, 2021 by an out of network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that there are in-network providers available for these 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 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 chiropractic services provided on January 5, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent. You say that the enrollee has been on nasal corticosteroids and oral steroids. You also say that the enrollee is not a candidate for surgery. The Plan denied your request. The Plan says this drug is not a covered benefit under the Part B plan.
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 Dupixent.
Benefits for Dupixent 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 stand-up walker.
You asked the Plan to pre-approve a stand-up walker. You say that this item is medically necessary. The Plan denied your request. The Plan says the enrollee has items that serve the same purpose as the requested item.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has walker and a cane. walker and a cane serves the same purpose as a stand-up walker. Therefore, we decided that the Plan does not have to pre-approve a stand-up walker.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve other drugs or medicaments (D9630 x 2).
You asked the Plan to pre-approve the other drugs or medicaments. You say that these services should be covered. The Plan denied your request. The Plan says other drugs or medicaments are not listed as 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 other drugs or medicaments (D9630 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).
You asked the Plan to pre-approve the denture. You say that you had dentures made in August 2020 that were ill fitting. You say that the provider insisted on adjusting the dentures, but they still did not fit right. It was 2021 by the time the provider decided to replace it entirely because the frame was warped or crooked. They billed your new insurance Plan without your knowledge or consent, despite the fact that they were made to replace previous dentures that never fit. The Plan made payment for the new dentures, but they are still ill-fitting. You want dentures to be provided by another dentist because you are dissatisfied with the care you were provided, and still have yet to receive functional dentures. The Plan denied your request. The Plan says they paid for a lower partial denture for you in January 2021. Dentures can only be covered once every 5 plan years.
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 can cover a complete denture for each jaw every 5 plan years.
Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for eye surgery (66984) provided February 9, 2021.
You asked the Plan to waive the copayment for the eye surgery. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for Outpatient Surgery services. You have been asked to pay a $325 copayment for the eye surgery. The eye surgery falls within the Outpatient Surgery services 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 eye surgery (66984) provided February 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep brain stimulation and associated hospital stay for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that when electric nerve stimulation is employed to treat motor function disorders, no reimbursement may be made for the stimulator or for the services related to its implantation since this treatment cannot be considered reasonable and necessary. We looked at the file and Medicare rules. These services are being requested to treat a motor function disorder. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve deep brain stimulation and associated hospital stay for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an intravitreal injection into the eye provided on December 10, 2020.
You asked the Plan to waive the copayment for an intravitreal injection into the eye. You say that you were never billed a copayment with the same codes on previous claims. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $450 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay a $304.97 copayment for an intravitreal injection into the eye. The record shows the Medicare Allowed Amount is $304.97, which is lower than your copayment of $450 per the EOC. Intravitreal injection into the eye 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 an intravitreal injection into the eye (67028) provided on December 10, 2020.
Your complaint about the Plan's previous claims processing 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 waive the coinsurance for a CPAP device and humidifier provided on September 3, 2020.

You asked the Plan to waive the coinsurance for a CPAP device and humidifier. You say that you should not be responsible for the coinsurance. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.

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 DME and related supplies.

The allowed amount of the claim for the CPAP device is $84.16, resulting in a coinsurance obligation of $16.83. The allowed amount of the claim for the CPAP humidifier is $216.13, resulting in a coinsurance obligation of $43.23. You have been asked to pay a 20% coinsurance for each DME item ($16.83 + $43.23 = $60.06). A CPAP device and humidifier fall within the DME and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) device and humidifier (E0601, E0562) provided on September 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of adequate conservative measures for low back pain, including physical therapy. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator for the enrollee.
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 you cannot walk or stand. You say that IRF care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for pulmonary embolism. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not use insulin. The elements of the local coverage rule are not satisfied. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.