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

 
We decided that the Plan does not have to pay for the comprehensive oral examination (D0150) provided on 
February 11, 2022. 
 
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 provided in this case has exceeded 
the allowable frequency. 
 
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 contract states that 
one comprehensive oral examination is covered every three Plan years. 
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the Plan covers one comprehensive oral examination 
every three years.  You previously received this service on February 1, 2022 that was paid for by the Plan. Therefore, 
you have exceeded the allowable benefit for this service. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral examination (D0150) provided on February 11, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for Trodelvy provided on December 9, 2021. 
 
You asked the Plan to pay for Trodelvy. You say that you would like this claim reprocessed based on the 
medical records. The Plan denied your request. The Plan says that experimental or investigational services are 
not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Trodelvy. Our reviewer says that the 
requested drug Trudelvy was medically reasonable and necessary. Our physician reviewer found that the 
enrollee has a diagnosis of metastatic urothelial cell carcinoma of the left renal pelvis, right distal ureter, lymph 
node and lung. Trodelvy is FDA-approved for the treatment of locally advanced or metastatic urothelial cancer 
who have previously received a platinum-containing chemotherapy and either PD-1 or PD-L1 inhibitor as is the 
case here. The enrollee in this case has been treated with a platinum-containing chemotherapy and a PD-1 
inhibitor. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trodelvy have been met. Therefore, we decided that the Plan has to pay for 
Trodelvy provided on December 9, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) provided on February 9, 2022. 
 
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 this service is not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99212) provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the cervical spine (72050) and the office 
visit (99202) provided on December 15, 2021. 
 
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 these services are not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the x-ray exam of the cervical spine (72050) and the office visit (99202) 
provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transport chair (E1038) provided on January 4, 2022, to 
February 4, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the transport chair. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as 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 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 a transport chair (E1038) provided on January 4, 
2022, to February 4, 2022 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on February 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that the provider said he was a new dentist and had recently been listed as an employee there. You also say 
that you were unaware of this. The Plan denied your request. The Plan says services performed by an OON 
provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that you 
did contact the Plan prior to the date of service to verify benefits, however, you did not ask about the network 
status for the provider you were treated by. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on 
February 28, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization administration by intramuscular injection of 
severe acute respiratory syndrome coronavirus 2 (0001A) provided December 9, 2021. 
 
You asked the Plan to pay for the COVID-19 immunization. You say that you have not been paid anything and 
the EOB explanation is vague. Please note, this is for a COVID vaccine which has been approved by the 
federal government. The Plan denied your request. The Plan says Medicare payment for COVID vaccinations administered during calendar years 2020 and 2021 to Medicare Advantage beneficiaries will be made through 
the Medicare FFS program. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the COVID-19 immunization have not been met. Therefore, we decided that the Plan does not have 
to pay for immunization administration by intramuscular injection of severe acute respiratory syndrome 
coronavirus 2 (0001A) provided December 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided February 22, 2022. 
 
You asked the Plan to pay for the limited oral exam. You say that this service was necessary to evaluate your 
dental health. 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 Plans coverage rules apply in this case. The Plan covers the limited 
oral exam once per plan year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on February 17, 2022. Based on this information, we decided that the Plan's frequency 
limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not 
have to pay for the limited oral evaluation - problem focused (D0140) provided February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with limited field of view  less than one whole jaw (D0364) provided February 1, 2022. 
 
You asked the Plan to pay for the cone beam CT scan. You say that this was a necessary service, and you were 
not informed that it would not be covered. 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 Plans 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 cone 
beam computed tomography (CT) capture and interpretation with limited field of view  less than one whole 
jaw (D0364) provided February 1, 2022.  
 Your complaint about potentially receiving inaccurate or incomplete information from a plan representative 
about coverage 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 pay for oral/facial photographic images (D0350 x 4) provided on 
March 14, 2022. 
 
You asked the Plan to pay for images. You say that the services were medically necessary. You also say that 
the Plan should pay first and that you should be responsible for the rest. The Plan denied your request. The Plan 
says oral/facial photographic images (D0350) are not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 oral/facial 
photographic images (D0350 x 4) provided on March 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair provided on November 26, 2021. 
 
You asked the Plan to pay for a shower chair. You say that you originally got a script for a regular tub seat, but 
it was dangerous because you kept tripping over and petrified falling in the shower. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 pay for a shower chair provided on November 26, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Imfinzi. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Durvalumab is FDA approved for stage III 
non-small cell lung cancer and for extensive stage small cell lung cancer. This enrollee does not have stage III 
NSCLC and small cell lung cancer is localized to 1 lymph node. The use of durvalumab in either of the 
enrollee's cancers has not been established. The service is not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Imfinzi.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of an erupted tooth or exposed root (D7140) 
provided on March 14, 2022. 
 
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 this service is not a covered benefit under 
your contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided in this case is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction of an erupted tooth or exposed root (D7140) provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia, anxiolysis (D9230), 
drugs or medicaments dispensed in the office for home use (D9630), collection and application of autologous 
blood concentrate product (D7921), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, 
and including elevation of mucoperiosteal flap if indicated (D7210), panoramic radiographic image 
(D0330), and limited oral evaluation - problem focused (D0140) provided September 21, 2021. 
 
You asked the Plan to pay for the inhalation of nitrous oxide, drugs dispensed in the office for home use, 
collection and application of autologous blood concentrate product, dental extraction, panoramic x-ray and 
limited oral exam. You say that the provider did not inform you that they had opted out of Medicare. The Plan 
denied your request. The Plan says these services are not covered because the provider 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. The Plan covers the inhalation 
of nitrous oxide, drugs dispensed in the office for home use, collection and application of autologous blood 
concentrate product, dental extraction, panoramic x-ray and limited oral exam when you see any licensed 
dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare 
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the inhalation of nitrous oxide, drugs dispensed in the office for 
home use, collection and application of autologous blood concentrate product, dental extraction, panoramic x-
ray and limited oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the 
inhalation of nitrous oxide/analgesia, anxiolysis (D9230), drugs or medicaments dispensed in the office for 
home use (D9630), collection and application of autologous blood concentrate product (D7921), extraction, 
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal 
flap if indicated (D7210), panoramic radiographic image (D0330), and limited oral evaluation - problem 
focused (D0140) provided September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for cataract surgery (66982, 00142) provided 
on January 12, 2022. 
 
You asked the Plan to waive the deductible for the cataract surgery. You say that the services should be 
covered as you disagree with the charges and your deductible was reset due to a delay caused by COVID-19. 
The Plan denied your request. The Plan says the deductible applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1000 deductible which applies to Vision care.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Vision care. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible 
which applies to Vision care. This cost sharing is a contractual obligation that had not been met at the time the 
cataract surgery was received on January 12, 2022. Therefore, we decided that the Plan does not have to waive 
the deductible for cataract surgery (66982, 00142) provided on January 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the enrollee indicates that the enrollee has chronic low back pain and 
lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has a body mass 
index of 48. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for hearing aid batteries (V5266) provided on July 19, 2021. 
 
You asked the Plan to pay for hearing aid batteries. You say that these services were medically necessary for 
this enrollee. The Plan denied your request. The Plan says that this service has a Medically Unlikely Edit 
(MUE) value of 0, which means that it cannot be paid under Medicare. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The Plan approved all of the hearing aid services at issue except for 
the hearing aid batteries. The Plan states that the reason for denial of this service is that code V5266 has an 
MUE value of 0. However, V5266 has an MUE value of 0 because is not a Medicare-covered service. It is 
worth noting that all of the other codes in this appeal which have been approved by the Plan also have an MUE 
value of 0, as Original Medicare does not cover hearing aids or hearing aid services. The issue in this case is 
not Medicare coverage of this service, but Plan coverage, as the Plan offers a supplemental benefit for hearing 
aid services. The hearing aid batteries are not listed as one of the items/services that are excluded under this 
benefit, and batteries are generally considered essential for the function of hearing aids. The Plan has provided 
no other reason for why this item should be denied. Based on this information, we decided that the Plan's rules 
for coverage of hearing aid batteries have been met. Therefore, we decided that the Plan has to pay for hearing 
aid batteries (V5266) provided on July 19, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered 
benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.