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

 We decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation - new or established patient (D0180).  You asked the Plan to pre-approve a comprehensive periodontal exam. You say that you would like this service covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers a dental exam twice per year.   We looked at the file and Medicare rules. In this case the Plan has covered a comprehensive oral exam on June 9, 2021, and November 17, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of a comprehensive periodontal exam has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation - new or established patient (D0180).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for famotidine 20MG injection (CPT code S0028) provided to the enrollee on March 8, 2021.  You asked the Plan to pay for the injection. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered 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.  CPT ode S0028 is assigned a status code I = Not valid for Medicare purposes. As the claim was billed with a CPT code which is invalid for usage with Medicare; we find that Medicare rule for payment of this claim has not been met. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay for famotidine 20MG injection (CPT code S0028) provided to the enrollee on March 8, 2021.
Appeal type: Drugs
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 requested device. You say that you have trouble pricking your fingers. The Plan denied your request. The Plan says criteria has not been met.  
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.   
 We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for an inpatient psychiatric admission provided on  April 26, 2021.   You asked the Plan to pay for an inpatient psychiatric admission. The Plan denied your request. The Plan says the inpatient psychiatric admission is not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 an inpatient psychiatric admission. Our reviewer says that the psychiatric admission was not medically necessary and reasonable. Our physician reviewer found that based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance including delusions, auditory or visual hallucinations. The health Plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this enrollee, it does not meet criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others, no auditory or visual hallucinations. He is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors as the enrollee awaited placement.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient psychiatric admission provided on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 2 heavy-duty power wheelchair and accessories.  You asked the Plan to pre-approve a power wheelchair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested items.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 heavy-duty power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pontic - porcelain/ceramic (D6245) and retainer crowns - porcelain/ceramic (D6740).  You asked the Plan to pre-approve a pontic and retainer crowns. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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 a pontic - porcelain/ceramic (D6245) and retainer crowns - porcelain/ceramic (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).  You asked the Plan to pre-approve the dental items. You say that you have limited income. You say that you cannot afford to pay for this procedure. You say that you had to have your teeth extracted because of an infection. You also say that you now need dentures. The Plan denied your request. The Plan says dentures 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 dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve addition to lower limb prosthesis, vertical shock reducing pylon feature (CPT code L5988).  You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. The Plan says the item is not necessary.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the item have not been met. The request includes L5988. This is part of prosthetic foot. It does not constitute a complete prosthetic foot and must be used in combination with a base foot code. Therefore, we decided that the Plan does not have to pre-approve addition to lower limb prosthesis, vertical shock reducing pylon feature (CPT code L5988).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and the bitewings - four radiographic images (D0274) provided September 15, 2021.  
You asked the Plan to pay for the panoramic x-ray and bitewing x-rays. You say that you did not want these services billed to insurance. The Plan denied your request. The Plan says the clams have been processed as billed. You have exceeded the frequency limit for these 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. The Plan covers bitewing x-rays twice per calendar year and full mouth or panorax x-rays once every 36 months.  
We looked at the file, and Medicare rules. In this case the Plan has previously covered 2 bitewing x-rays and a panoramic x-ray. Based on this information, we decided that the Plan's frequency limits for coverage of the panoramic x-ray and bitewing x-rays have been exceeded. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and the bitewings - four radiographic images (D0274) provided September 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided on March 17, 2021.  You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.  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 on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and limited oral evaluation - problem focused (D0140) provided May 4, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the panoramic x-ray and limited oral exam. You say that you were told to go to this provider and would like the services covered. The Plan denied your request. The Plan says these services are not covered when provided OON. Additionally, the Plan says they have contacted the dental vendor who has no record of giving information referring you to this OON provider.  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 panoramic x-ray and limited oral exam when the services are provided by a dental network provider.  We looked at the file and Medicare rules. In this case the services were provided OON. Based on this information, we decided that the Plan's rules for coverage of the panoramic x-ray and limited oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and limited oral evaluation - problem focused (D0140) provided May 4, 2021 by an out-of-network (OON) provider.   Your complaint about potentially receiving misinformation 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an urgent care visit provided on July 11, 2021.  You asked the Plan to waive the copayment for the urgent care visit. You say that you were informed that there was no copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  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 $30 copayment for each visit to an urgent care center or walk-in clinic.   You have been asked to pay a $30 copayment for the urgent care visit. Urgent care visits fall within the Urgently Needed 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 an urgent care visit provided on July 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a leadless pacemaker.  You asked the Plan to pre-approve a leadless pacemaker. You say that the enrollee feels this is the best option for her. You also say that known infectious and procedure risks for the leadless device are lower than that of traditional transvenous systems. The Plan denied your request. The Plan says the enrollee is not requested this service as part of an FDA approved study.  The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are covered when procedures are performed in Food and Drug Administration (FDA) approved studies.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a leadless pacemaker have not been met. Specifically, the file does not indicate that the enrollee is not part of an FDA approved study. Therefore, we decided that the Plan does not have to pre-approve a leadless pacemaker.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the therapeutic exercises (97110) provided June 1, 2021, to June 17, 2021.  You asked the Plan to waive the copayment for the physical therapy services. You say that you were unaware that there would be a copayment and don't believe you should have to pay it. The Plan denied your request. The Plan says the copayment was 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 $35 copayment for Medicare; covered Physical Therapy (in person or virtual) visits.  You have been asked to pay a total of $210 copayment ($35 copayment x 6 visits = $210) for the physical therapy services. The physical therapy services fall within the Outpatient rehabilitation 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 the therapeutic exercises (97110) provided June 1, 2021, to June 17, 2021.   Your complaint about not feeling adequately informed by the Plan or provider about the copayment 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 clinical crown lengthening - hard tissue (D4249).  You asked the Plan to pre-approve clinical crown lengthening. You say that this service is necessary to place a crown. 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 clinical crown lengthening - hard tissue (D4249).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Dexcom G6 transmitter.  
You asked the Plan to pre-approve a Dexcom G6 transmitter. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.   We looked at the file and Medicare rules. The documentation indicates that the enrollee does not 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 a Dexcom G6 transmitter have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 transmitter.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gemtesa 75 mg tablet.  You asked the Plan to pre-approve Gemtesa. You say that this requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the Plan's medical 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 Gemtesa 75 mg tablet.   Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you the full amount for eyeglasses provided on  July 23, 2021.  You asked the Plan to reimburse you the full amount for the eyeglasses. You say that you were told by the vision vendor that the eyeglasses would be covered from the out-of-network provider. The Plan denied your request. The Plan says the Plan will reprocess the claim to pay the maximum vision allowance of $400, and the remaining $49 will be your responsibility as the vision benefit has been exhausted. Members are responsible for all costs over and above the allowance amount.  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.   We looked at the file and the Plan's rules. The file shows that the Plan will reprocess the claim to pay the maximum vision allowance of $400, and the remaining $49 will be your responsibility as the vision benefit has been exhausted. Members are responsible for all costs over and above the allowance amount. Therefore, we decided that the Plan does not have to reimburse you the full amount for eyeglasses provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental services provided on July 19, 2021.  You asked the Plan to pay for the dental services. You say that being in pain in your mouth and ear is not something you want to have all day. You say that seeing this doctor was justified and the claim should be reversed and paid. The Plan denied your request. The Plan says you will not receive reimbursement if you use a provider that has opted out of Medicare.  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, dental services provided by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the topical application of fluoride (D1208) and localized delivery of antimicrobial agents (D4381) provided on May 25, 2021.  You asked the Plan to pay for the topical application of fluoride (D1208) and localized delivery of antimicrobial agents (D4381). You say that you confirmed the procedures would be covered in full, so you had the procedures done. You say that you are on a fixed income and should be reimbursed due to being misinformed. The Plan denied your request. The Plan says the topical application of fluoride and localized delivery of antimicrobial agents 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 topical application of fluoride (D1208) and localized delivery of antimicrobial agents (D4381) provided on May 25, 2021.