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

We decided that the Plan does not have to pre-approve a DyAnsys Primary Relief Device.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. The requested device is being used as acupuncture treatment not for chronic low back pain. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-approve a DyAnsys Primary Relief Device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthroscopy services coded 29826 provided on January 5, 2021.
You asked the Plan to pay for the arthroscopy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 29826 is arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure). We find that CPT code 29826 is not supported in the medical record. Specifically, the operative report did not include documentation of a surgical shoulder arthroscopy, with decompression of subacromial space with a partial acromioplasty, with or without coracoacromial ligament (arch) release (listed separately in addition to code for primary procedure); therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the arthroscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the arthroscopy services coded 29826 provided on January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that your husband has fallen multiple times. The Plan
denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because
they are not primarily medical in nature.
While a grab bar 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 grab bar.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal adjustment - complete (D9952).
You asked the Plan to pre-approve an occlusal adjustment. You say that this service is medically necessary to improve function. The Plan denied your request. The Plan says this service 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. 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 an occlusal adjustment - complete (D9952).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic consultation with a dentist or physician other than the requesting dentist/physician (D9310).
You asked the Plan to pre-approve the consultation. You say that this service is necessary, and you cannot afford the cost. The Plan denied your request. The Plan says this service 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 diagnostic consultation with a dentist or physician other than the requesting dentist/physician (D9310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) for tooth # 15 provided on March 23, 2021.
You asked the Plan to pay for the dental service. You say that you were in pain before the date of service. You say that you got the crown done so that you would not need a root canal. You also say that you would like for this service to be paid. The Plan denied your request. The Plan says the tooth does not appear to have significant breakdown due to decay or trauma.
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 pay for the dental service. Our reviewer says that the crown for tooth # 15 is not medically necessary. Our physician reviewer found the provided documentation does not show significant coronal breakdown to warrant a crown restoration for tooth # 15. Therefore, the reviewer found that the crown for tooth # 15 is not medically reasonable or necessary. 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 pay for the porcelain crown (D2740) for tooth # 15 provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit (99203, S9088) provided on November 8, 2020.
You asked the Plan to waive the copayment. 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 $50 copayment for each urgent care visit. You have been asked to pay a $50 copayment for the urgent care visit 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 copayment for the urgent care visit (99203, S9088) provided on November 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out of network (OON) provider on November 13, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered 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 had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out of network (OON) provider on
November 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 5.
You asked the Plan to pre-approve the dental service. You say that the service is medically necessary. The Plan denied your request. The Plan says core build up 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 core build up (D2950) for tooth # 5.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network provider.
You asked the Plan to pre-approve physical therapy. You say that after a few visits with this provider you were making incredible progress and ultimately became pain free. The Plan denied your request. The Plan says the services are available in-Plan and the member is contractually required to obtain this service 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 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 out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950) and porcelain with high noble
metal crown (D2750) for tooth #8.
You asked the Plan to pre-approve the crown and core buildup. You say that this crown was not done properly
when you had the last procedure, and it became loose and was subsequently swallowed. Replacement of this
crown is necessary. The Plan denied your request. The Plan says these services can only be covered once per
tooth every 5 years. The Plan previously paid for a core buildup and crown for tooth #8 in 2018, which is less
than 5 years before the date of this request.
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 crown
and core buildup once per tooth every 5 plan years.
Though the Plan offers a dental benefit in excess of Medicare coverage, the items or services are requested in a
frequency beyond what is covered under this benefit. Documentation shows that the Plan paid for a previous
crown and core buildup for the requested tooth less than 5 years ago. Therefore, we decided that the Plan does
not have to pre-approve a core buildup (D2950) and porcelain with high noble metal crown (D2750) for tooth
#8.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the screening mammography provided on August 11, 2020.
You asked the Plan to pay for the screening mammography (77067). You say that the service was rendered appropriately in response to the enrollee's medical condition. The Plan denied your request. The Plan says that they need approvals in order to proceed with the provider's request to reprocess the denied/reinstated claim.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any rules, citations, screen prints, etc. to support their decision. Therefore, we decided that the Plan has to pay for the screening mammography provided on August 11, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth #29.
You asked the Plan to pre-approve the crown. You say that you had another dental plan but cancelled it because you thought you had enough coverage with the Plan's supplemental benefit. You are frustrated and now feel that you do not have enough coverage. The Plan denied your request. The Plan says crowns are not covered by the base dental benefit that comes with your medical plan. The Plan offers an additional optional dental benefit for an extra monthly premium and has indicated that they are handling your grievance as a separate issue.
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/ceramic crown (D2740) for tooth #29.
Your complaint about a potential miscommunication from the Plan and the coverage provided 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of lateral exostosis (D7471 x 2), and the collection and application of autologous blood concentrate product (D7921 x 2).
You asked the Plan to pre-approve the dental services. You say that you have been in discomfort for over a year now. You also say that you cannot eat or talk without your denture coming out. The Plan denied your request. The Plan says removal of lateral exostosis are not listed as covered services. The Plan also says that collection and application of autologous blood concentrate product are not listed as covered services 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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of lateral exostosis (D7471 x 2), and the collection and application of autologous blood concentrate product (D7921 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hyperice venom back heat and vibration wrap.
You asked the Plan to pre-approve these services. You say that the item is to help with your back pain. The Plan denied your request. The Plan says the item is not covered.
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 hyperice venom back heat and vibration wrap.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq, extended release, 25 mg tablet.
You asked the Plan to pre-approve Myrbetriq. You say that the enrollee's diagnosis makes using anticholinergics less safe. You also say that Myrbetriq is safe as it is a beta 2 agent. 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 Myrbetriq, extended release, 25 mg tablet.
Benefits for Myrbetriq 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nail trimming services.
You asked the Plan to pre-approve these services. You say that you have arthritis in both knees, hips, and back and your toenails are causing pain. The Plan denied your request. The Plan says the services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. Records do not show that any of these conditions are present. The services you are asking the Plan to pre-approve are routine foot care services. 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 nail trimming services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tympanometry (92567) and the comprehensive hearing test (92557) rendered by the out of network (OON) provider on May 13, 2020.
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 rendered 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 had network providers available who could have provided 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 tympanometry (92567) and the comprehensive hearing test (92557) rendered by the out of network (OON) provider on May 13, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve DyAnsys Primary Relief Auricular Percutaneous Nerve Stimulation therapy.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case. We looked at the file and Medicare rules. The file shows that the requested device is being used as acupuncture treatment not for chronic low back pain. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pre-approve DyAnsys Primary Relief Auricular Percutaneous Nerve Stimulation therapy.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional non-emergent transportation trips.
You asked the Plan to provide coverage for additional non-emergent transportation trips. You say that you have several appointments coming up and you have been in and out of the hospital. You say that you have no family or friends who can assist with transportation. The Plan denied your request. The Plan says the request exceeds the Plan's benefit allowance.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. The file shows that the Plan covers 24 one-way non-emergent transportation trips every year. Therefore, we decided that the Plan does not have to provide coverage for additional non-emergent transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain crown (D2740) for teeth # 8 and 9.
You asked the Plan to pre-approve the dental services. You say that you went for a second opinion. You say that you were told the crowns need to be done all over again since they were not bonded correctly. You also say that you bite your lip when you chew because your crowns were not placed properly. The Plan denied your request. The Plan says crowns are covered once per tooth, every 5 plan years. The Plan also says that the frequency limit has 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 are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for crowns for teeth # 8 and 9 that you received on August 14, 2019. Therefore, we decided that the Plan does not have to pre-approve porcelain crown (D2740) for teeth # 8 and 9.