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

We decided that the Plan does not have to pre-approve Nurtec Tab.
You asked the Plan to pre-approve Nurtec Tab. You say that the enrollee has tried and failed other medications but this one significantly improves her condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug benefit.
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 Nurtec Tab.
Benefits for Nurtec Tab 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on November 6,
2020.
You asked the Plan to pay for the emergency room services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that the emergency room services are not supported in the medical record. Specifically, these services
were billed with an incorrect type of bill code. Based on this information, we decided that Medicare rules for
coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have
to pay for the emergency room services provided on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5258, V5254) received October 12, 2020.
You asked the Plan to pay for the hearing aids. You say that a Plan representative said you would receive some reimbursement for the hearing aids. The Plan denied your request. The Plan says hearing aids are not covered by the enrollee's plan.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. The Plan contract clearly states that there is no coverage for hearing aids. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5258, V5254) received October 12, 2020.
Your complaint about receiving incorrect information from a plan representative 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 an abutment supported porcelain/ceramic crown (D6058).
You asked the Plan to pre-approve the abutment supported porcelain/ceramic crown. You say that this service was denied because the crown is supported by an abutment instead of the tooth. You also say that it is misleading to deny any payment for the crown. The Plan denied your request. The Plan says this service is 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an abutment supported porcelain/ceramic crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D6010, D1999, D7953) received January 21, 2021.
You asked the Plan to pay for the dental services (D6010, D1999, D7953). You say that other services were approved before and this claim should be paid as well. 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 dental services (D6010, D1999, D7953) received January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging, posterior segment (92134) and the office visit (99213) provided on February 10, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the scanning computerized ophthalmic diagnostic imaging and the office visit. You say that you did not know you needed pre-approval for these services. The Plan denied your request. The Plan says criteria for obtaining out-of-network coverage is not met.
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 the scanning computerized ophthalmic diagnostic
imaging, posterior segment (92134) and the office visit (99213) provided on February 10, 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 comprehensive oral evaluation (D0150) and treatment of root canal obstruction (D3331) to be provided by an endodontist.
You asked the Plan to pre-approve the comprehensive oral evaluation and treatment of root canal obstruction. You say that you are in pain and would like to have your tooth fixed. The Plan denied your request. The Plan says there is no benefit for a root canal or for services to be performed by an endodontist.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
comprehensive oral evaluation (D0150) and treatment of root canal obstruction (D3331) to be provided by an
endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve the dental item. You say that you lost your top denture. You also say that you want to know when this will be covered again. The Plan denied your request. The Plan says complete upper denture is covered once 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 complete upper denture is listed as a covered service, the frequency limit has been reached. The record shows that you received a complete upper denture on October 30, 2019. You will not be eligible for a new complete upper denture to be paid until October 30, 2024. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 20, 2021.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses you received on March 11, 2021.
You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says the
services were provided from an out of network provider. Your Plan benefits do not include out-of-network
benefits.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services when provided by a network optical provider.
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's
network optical provider. Based on this information, we decided that the Plan's rules for coverage of the
eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for
eyeglasses you received on March 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve Ondansetron. The Plan denied your request. The Plan says this drug is self-administered, and does not meet Medicare criteria for coverage under 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 Ondansetron.
Benefits for Ondansetron 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing for arsenic (82175), cadmium (82300), chromium
(82495), ferritin (82728), glycosylated hemoglobin (83036), lead (83655), and mercury (83825) provided on
July 17, 2020.
You asked the Plan to pay for testing for arsenic, cadmium, chromium, ferritin, glycosylated hemoglobin, lead,
and mercury. You say that this was necessary due to the pandemic. The Plan denied your request. The Plan
says these tests were screening tests.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The tests at issue in this appeal, testing for arsenic, cadmium, chromium, ferritin, glycosylated hemoglobin,
lead, and mercury, were requested solely for screening purposes. Medicare does not cover this test solely for
screening purposes. Therefore, we decided that the Plan does not have to pay for testing for arsenic (82175),
cadmium (82300), chromium (82495), ferritin (82728), glycosylated hemoglobin (83036), lead (83655), and
mercury (83825) provided on July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - four or more surfaces, posterior (D2394), the resin-based composite - one surface, posterior (D2391) and the resin-based composite - two surfaces, anterior (D2331) received March 2, and March 16, 2021.
You asked the Plan to pay for the resin-based composite (D2394, D2391, D2331). You say that you did not know only two fillings would be covered per year. The Plan denied your request. The Plan says your benefit is limited to two filling procedures per calendar year.
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 resin-based composite (D2394, D2391, D2331) when the services are medically necessary and reasonable.
We looked at the file, and Medicare rules. The Plan only covers up to two filling procedures per calendar year. The Plan covered two fillings, on tooth #11 and tooth #12 received on March 2, 2021. The benefit for fillings has been exhausted for the 2021 calendar year. Therefore, we decided that the Plan does not have to pay for the resin-based composite - four or more surfaces, posterior (D2394), the resin-based composite - one surface, posterior (D2391) and the resin-based composite - two surfaces, anterior (D2331) received March 2, and March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue regeneration (D4265).
You asked the Plan to pre-approve the biologic materials. You say that you need the extraction to treat the open sinus because your dentist told you it could be dangerous if he cannot have this procedure. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 biologic materials to aid in soft and osseous tissue regeneration (D4265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944) and crown (D2740) provided on
December 4, 2020, and December 30, 2020.
You asked the Plan to pay for the occlusal guard and crown. You say that you were in a great deal of pain and
discomfort with tooth #15 because the original crown had broken in September or October. The Plan denied
your request. The Plan says the occlusal guard is not a covered service. The Plan also says that the crown was
not unforeseen, and you became effective with the dental insurance on November 1, 2020, which is after the
problem developed.
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, occlusal guard (D9944) is not among
those covered under this benefit. The contract also says that there is a 6 month waiting period (after eligibility)
to receive a crown (D2740). The record shows that you did not become effective with the dental plan until
November 1, 2020, and the issue began in September or October. The 6 month waiting period after eligibility
has not been met. Therefore, we decided that the Plan does not have to pay for the occlusal guard (D9944) and
crown (D2740) provided on December 4, 2020, and December 30, 2020
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for hernia repair hospital services provided on
February 20, 2020.
You asked the Plan to pay for hernia repair hospital services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 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 hernia repair hospital services provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the retainer crown - porcelain/ceramic (D6740), and the pontic - porcelain/ceramic (D6245).
You asked the Plan to pre-approve the retainer crown - porcelain/ceramic (D6740), and the pontic - porcelain/ceramic (D6245). You say that the requested services are necessary. 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 pre-approve the retainer crown - porcelain/ceramic (D6740), and the pontic - porcelain/ceramic (D6245).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from September 30, 2019, through November 19, 2019.
You asked the Plan to pay for the physical therapy services. 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 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 physical therapy services provided from September 30, 2019, through November 19, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97530 provided on August
17, 2020.
You asked the Plan to pay for the therapeutic procedure. 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 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation indicates
that the service was performed by an occupational therapist assistant in a home health or hospice setting. There
is a more appropriate code to be used for the services provided. Based on this information, we decided that
Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the
Plan does not have to pay for the therapeutic procedure coded 97530 provided on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the insert will help his blood level and help with pain that is hurting the tendon foot. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that this equipment would be beneficial for his wife so they can access their shower, sponge baths are given to the enrollee and there is great difficulty trying to get upstairs to reach the shower. 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 stair lifts are not covered because they are not primarily medical in nature. While a stair lift 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 stair glide
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 fillings (D2332/D2391/D2393), 2 crowns (D2740), 5 core build up (D2950), a prefabricated post and core in addition to a crown (D2954), a root canal (D3320), 4 retainer crowns (D6740), 2 pontics (D6245), and 3 extractions.
You asked the Plan to pre-approve the dental services. You say that you would like to get these services done so that you can avoid having your teeth extracted. The Plan denied your request. The Plan says the requested services are not considered preventive dental services. The Plan also says that the requested dental services are not listed as 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, your coverage is limited to preventive
dental services. The requested services are not preventive dental services. Therefore, we decided that the Plan does not have to pre-approve 7 fillings (D2332/D2391/D2393), 2 crowns (D2740), 5 core build up (D2950), a prefabricated post and core in addition to a crown (D2954), a root canal (D3320), 4 retainer crowns (D6740), 2 pontics (D6245), and 3 extractions.