Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hysterectomy surgery.
You asked the Plan to pre-approve hysterectomy. You say that given the enrollee's medical history, you recommend she pursue definitive treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the requested surgery 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 hysterectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has no documented history of moderate/severe cervical dysplasia, which is typically the threshold for excision of the cervix. Diagnostic excision is acceptable if cervical intraepithelial neoplasia (CIN1) persists for 2 years or more, widely accepted as a standard of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hysterectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve hysterectomy surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot tub (A9270) and sales tax (S9999) purchased May 5,
2019 from an out of network provider.
You asked the Plan to pay for the hot tub and sales tax. You say that your doctor said the equipment would aid
in relieving some of your chronic back pain and that hydrotherapy would benefit you so that you could perform
basic daily activities with less pain. The Plan denied your request. The Plan says these items are not covered
under Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for the hot tub (A9270) and sales tax (S9999) purchased May 5,
2019 from an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One. You asked the Plan to pre-approve the Synvisc-One. You say that you would like reconsideration because this drug is medically necessary for the treatment of your condition. The Plan denied your request. The Plan says you do not meet step therapy exception criteria. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Synvisc-One. Our reviewer says that health plan requires that other forms of hyaluronic acid injections be used. There is no evidence that you are allergic to or intolerant of these other forms of hyaluronic acid. Our physician reviewer found there is no evidence that you have tried and not responded to these other forms of hyaluronic acid injections. There is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and effective for you. 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates the enrollee does not have diabetes. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Electroencephalogram (EEG) and the allergy testing services provided on February 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you were never seen by this provider. The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.
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 has network providers available who can provide 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 the Electroencephalogram (EEG) and the allergy testing services provided on February 25, 2020 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 maxillary partial denture.
You asked the Plan to pre-approve the maxillary partial denture. You say that you received your prosthesis in August, but in February you were brushing your teeth and your tooth fell out. You also say that you called to ask for an appointment, but were told the provider you requested no longer works there. The Plan denied your request. The Plan says your maxillary denture benefit has been exhausted.
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, partial dentures are limited to one upper and/or one lower partial denture every five years. The record shows that you received a maxillary partial denture on May 1, 2019 and your dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve a power seat elevation feature. You say that this is necessary for you to
reach things in your environment. The Plan denied your request. The Plan says that this is not covered by
Medicare.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered
because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve
a power seat elevation feature (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveface masks (E1399).You asked the Plan to pre-approveface masks. You say that you were told by your doctor that that you are high risk and if you get COVID 19 you would end up going to dialysis. You have low income and cannot afford the masks.The Plan denied your request. The Plan says this item is not covered under Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approveface masks (E1399).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on March 12, 2020.
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that your provider said this was a routine mammogram and would be covered. 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 $50 copayment for each in-network Medicare-covered x-ray performed in an Outpatient Hospital Facility. You have been asked to pay a $50 copayment for a diagnostic mammogram. Diagnostic mammograms fall within the outpatient diagnostic tests and therapeutic services and 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 copayment for a diagnostic mammogram provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe PALB2 genetic testing rendered on February 4, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that will reimburse approved testsWe looked at the file and Medicare rules. The PALB2 genetic testing has not been approved through the program. 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 pay forthe PALB2 genetic testing rendered on February 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays and oral evaluation provided on March 3, 2020.
You asked the Plan to pay for the intraoral x-rays. You say that you were in extreme tooth pain. You say that you contacted the Plan to make sure you would be covered after the copayment. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays and oral evaluation provided on March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance provided on January 27, 2020 and the limited oral evaluation and intraoral x-ray provided on March 2, 2020.
You asked the Plan to pay for the periodontal maintenance, limited oral evaluation and intraoral x-ray. You say that you have gone to this office for many years for cleaning and care. You say that you paid for both visits and are asking to be refunded. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal maintenance provided on January 27, 2020 and the limited oral evaluation and intraoral x-ray provided on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray provided on January 23, 2020.You asked the Plan to pay forthe first intraoral periapical x-ray. You say that the Plan's website was not clear that this treating provider was in-network at a location further from your home. You also say that you cannot afford to pay for this claim.The Plan denied your request. The Plan says this service 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 thatthe Plan does not have to pay forthe first intraoral periapical x-ray provided on January 23, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite, bitewings, and amalgam provided on March 3, 2020.You asked the Plan to pay for the resin-based composite, bitewings, and amalgam. You say that you called the Plan on March 2, 2020 after you received your comprehensive dental card with an effective date of April 1, 2020, to check if you had dental coverage, and were informed that you do have coverage.The Plan denied your request. The Plan says these services are not covered. The Plan also says that your 2020 Dental Plan became effective after these services were rendered.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. The records show that the Plan informed you of the included preventive benefits that were covered when you spoke with them, and you were not misinformed.Therefore, we decided that the Plan does not have to pay for the resin-based composite, bitewings, and amalgam provided on March 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided March 10, 2020.You asked the Plan to pay for the paramedic intercept services. You say that it is your understanding that the paramedic is automatically dispatched by 911 for serious conditions. You had no control in who responded, that is determined by 911.The Plan denied your request. The Plan says this service is a non-covered ambulance service.The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that there is no contract between the ALS paramedic intercept provider does not have a contract with the volunteer ambulance company that provided the transport services.Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided March 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided from November 15, 2019 to November 20, 2019.You asked the Plan to pay forthe self-administered drugs. The Plandenied your request. The Plan says self-administered drugs are not covered services under your 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 drugsrequested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe self-administered drugs provided from November 15, 2019 to November 20, 2019.Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe 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 pay more for the prophylaxis, oral evaluation and bitewing x-rays provided on February 18, 2020.
You asked the Plan to pay more for the prophylaxis, oral evaluation and bitewing x-rays. You say that the coverage information indicates a $40 out-of-network copayment. You say that you should have been reimbursed $226 after the $40 copayment. The Plan denied your request. The Plan says the claim processed correctly.
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 Plan is only obligated to pay $56 toward the claim. The records show that the services were received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay more for the prophylaxis, oral evaluation and bitewing x-rays provided on February 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Oxycodone tablet, Atorvastatin tablet, Brimonidine drops, Tamsulosin capsules, Dorzolamide drops, Pantoprazole tablet, and Hydrochorothiazide tablet provided on January 9, 2020 and January 10, 2020.You asked the Plan to pay forthe self-administered drugs. You say that these drugs were givento you during the time you spent in the hospital. You also say that the facility said you would not be able to bring your own medications.The Plan denied your request. The Plan says these medications are considered self-administered drugs, and needs tobe processed under your Part D benefits.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 byMedicare Part B.Therefore, we decided that the Plan does not have to pay forthe Oxycodone tablet, Atorvastatin tablet, Brimonidine drops, Tamsulosin capsules, Dorzolamide drops, Pantoprazole tablet, and Hydrochorothiazide tablet provided on January 9, 2020 and January 10, 2020.Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe 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 pay for the problem focused limited oral evaluation (D0140) provided on February 24, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you had an infected tooth and wanted to have the issue taken care of quickly. The Plan denied your request. The Plan says the service exceeds the frequency limitation in your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluations (D0140) are limited to one procedure per plan year. The record shows that you received two problem focused limited oral evaluations (D0140 x2) on February 24, 2020, one of which was covered by the Plan, and your problem focused limited oral evaluations (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a white glass with high gold content crown on tooth #25 (D2750)
You asked the Plan to pre-approve a crown on tooth #25. You say that this is medically necessary. The Plan denied your request. The Plan says this tooth has advanced periodontal disease and significant bone loss.
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 a crown on tooth #25 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 a crown on tooth #25. Our reviewer says that the requested crown is not medically necessary at this time. Our physician reviewer found the provided information does not indicate there is pathologic destruction of the tooth that involves four or more surfaces and at least 50% of the incisal edge. The x-ray shows an existing mesio-facial or mesio-lingual restoration of moderate size, but not involving more than three surfaces and not involving the incisal edge. The existing restoration does not appear to have recurrent decay or seen to be defective. 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 a crown on tooth #25 have not been met. Therefore, we decided that the Plan does not have to pre-approve a white glass with high gold content crown on tooth #25 (D2750)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Scaling and Root Planing (D4341).
You asked the Plan to pre-approve Scaling and Root Planing. You say that the scaling and root planing is medically necessary. The Plan denied your request. The Plan says coverage criteria is not met.
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 Scaling and Root Planing 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 Scaling and Root Planing. Our reviewer says that the scaling and root planing is not medically necessary. Our physician reviewer found the code provided for scaling and root planing was D4341, which is reserved for a quadrant of four or more teeth. Despite the noted bone loss on teeth #23 and #21, the code is incorrect as radiographs show less than 4 teeth in the quadrant and cannot be approved. 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 Scaling and Root Planing have not been met. Therefore, we decided that the Plan does not have to pre-approve Scaling and Root Planing (D4341).