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

We decided that the Plan does not have to pay for the self-administered drugs (aspirin, tylenol, carvedilol, amlodipine, tamsuloine, and clopidogrel).
You asked the Plan to pay for the self-administered drugs. You say that you want to appeal the claims for the self-administered drugs. The Plan denied your request. The Plan says their initial decision to deny the self-administered drugs was correct.
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 pay for the self-administered drugs (aspirin, tylenol, carvedilol, amlodipine, tamsuloine, and clopidogrel).
Benefits for the self-administered drugs 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 pre-approve removal of lateral exostosis and guided tissue regeneration dental services.
You asked the Plan to pre-approve these services. You say that you want to appeal the denial. 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 pre-approve removal of lateral exostosis and guided tissue regeneration dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone growth stimulator provided on March 22, 2021.
You asked the Plan to pay for the bone growth stimulator. You say that the criteria are met, and this should be reimbursed. The Plan denied your request. The Plan says the claim was not billed in accordance with the ICD-10 guidelines.
The Plan must follow Medicare rules. Medicare rules say that the ICD-10 guidelines indicate that when using the 7th character of S for a diagnosis code, this is appended to the injury code and the actual diagnosis of the sequela is sequenced first. This claim has the injury code sequenced first followed by the sequela. This is not in accordance with the guidelines. Therefore, we decided that the Plan does not have to pay for the bone growth stimulator provided on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the extended respiratory pathogen panel by polymerase chain reaction (PCR) provided on September 21, 2020.
You asked the Plan to pay for the respiratory pathogen panel by PCR. You say that this was medically necessary as per the ordering physician. The Plan denied your request. The Plan says this was billed with an invalid POS code.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the respiratory pathogen panel by PCR have not been met. Therefore, we decided that the Plan does not have to pay for the extended respiratory pathogen panel by polymerase chain reaction (PCR) provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies and materials (99070) provided February 22, 2021.
You asked the Plan to pay for supplies and materials. You say that the services are separately payable. The Plan denied your request. The Plan says this is a bundled code.
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, we have confirmed that code 99070 is bundled. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for supplies and materials (99070) provided February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames, trifocal eyeglass lens, anti-reflective coating, and vision service (V2020, V2750, V2799, V2303) on April 27, 2021.
You asked the Plan to pay for the routine vision services. You say that you had to pay $259 for the services. The Plan denied your request. The Plan says it will cover up to $350 per calendar year and this amount was exhausted.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when The Plan has a $350 allowance every calendar year, but if the purchase costs exceeds $350, you must pay the difference. We looked at the file and the Plan's rules. The $350 benefit limit has been exhausted for 2021. It was exceeded in this visit. Based on this information, we decided that the Plan's rules for coverage of the routine vision services have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames, trifocal eyeglass lens, anti-reflective coating, and vision service (V2020, V2750, V2799, V2303) on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft (D7953), an alveoloplasty in conjunction with extractions (D7310), guided tissue regeneration (D4266) and an implant body placement (D6010) provided on July 14, 2020, to October 6, 2020.
You asked the Plan to pay for A bone replacement graft, an alveoloplasty in conjunction with extractions, guided tissue regeneration and an implant body placement are not listed as a covered benefit. You say that you do not agree with the denial of the claim. The Plan denied your request. The Plan says the services requested are purely dental in nature. They are unrelated to the limited clinical indications. The Plan also says that the services are not eligible for coverage under the medical 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. 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 a bone replacement graft, an alveoloplasty in conjunction with extractions, guided tissue regeneration and an implant body placement. Our reviewer says that the services are not medically necessary. Our physician reviewer found the documentation provided and the EOC by the plan does not meet the criteria for coverage for the services indicated. 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 bone replacement graft, an alveoloplasty in conjunction with extractions, guided tissue regeneration and an implant body placement have not been met. The EOC confirms that services that are not listed, are not covered benefits and you will be responsible for the full cost. Therefore, we decided that the Plan does not have to pay for a bone replacement graft (D7953), an alveoloplasty in conjunction with extractions (D7310), guided tissue regeneration (D4266) and an implant body placement (D6010) provided on July 14, 2020, to October 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine eyewear (V2204, V2203, V2750, V2020).
You asked the Plan to pay for the routine eyewear. You say that the Plan was incorrect in tallying the amount owed on the claim. The Plan denied your request. The Plan says their decision was correct to deny coverage beyond the $300 allowance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the Plan has a $300 benefit for vision care per year. The Plan also says that if you exceed the allowance, you must pay the difference. We looked at the file and the Plan's rules. You have exceeded your $300 benefit for 2021. Based on this information, we decided that the Plan's rules for coverage of the routine eyewear have not been met. Therefore, we decided that the Plan does not have to pay for routine eyewear (V2204, V2203, V2750, V2020).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (Levothyroxine Sodium and Folic Acid).
You asked the Plan to pay for the self-administered drugs. You say that you should not have to pay for medications that you take from home. The Plan denied your request. The Plan says the self-administered drugs are not eligible for coverage.
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 pay for self-administered drugs (Levothyroxine Sodium and Folic Acid).
Benefits for the self-administered drugs 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 pre-approve a root canal (endodontic therapy).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
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 root canal (endodontic therapy).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care provided on June 14, 2021, to June 21, 2021,
by an out-of-network (OON) provider.
You asked the Plan to pay for the wound care. You say that it was your understanding that the facility accepted
your insurance and that you were covered per your doctor's referral. The Plan denied your request. The Plan
says no prior authorization was 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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the wound care provided on June 14, 2021, to June 21, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator.
You asked the Plan to pre-approve an oxygen concentrator. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have an oxygen concentrator. Your current oxygen concentrator serves the same
purpose as the requested oxygen concentrator. There is no documentation in the case file to support you're your
current oxygen equipment is damaged beyond repair, stolen, or lost. Therefore, we decided that the Plan does
not have to pre-approve an oxygen concentrator.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the colonoscopy, provided on June 10,
2021.
You asked the Plan to waive the deductible for the colonoscopy. You say that the service should be covered.
The Plan denied your request. The Plan says the cost share 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 $125
copayment after the $750 deductible is met for each outpatient surgery and/or services at an ambulatory
surgical center or outpatient hospital facility
You have been asked to pay $99.25 of the remaining deductible for the colonoscopy. This service falls within
the outpatient surgery 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 deductible for the
colonoscopy, provided on June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair armrest pouch (K0108).
You asked the Plan to pre-approve the wheelchair armrest pouch. You say that the item is medically necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the wheelchair armrest pouch (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you had on March 16, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you cannot afford this cost sharing. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for lab tests. You have been asked to pay a $10 copayment for the lab services. 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 lab services you had on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two retainer crowns (D6750 x2).
You asked the Plan to pre-approve the retainer crowns. You say that you would like to appeal these services because the denied teeth are upper (superior) teeth, and you cannot be left without them. You also say that you are unable to afford the expense of the denied services. The Plan denied your request. The Plan says the maximum limit of your coverage contract of $2,500 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, the Plan offers up to $2,500 every year for comprehensive dental services.
The record shows that you were approved for two retainer crowns (D6750 x2) and four pontics (D6240 x4) totaling $2,500, and your annual maximum dental benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve two retainer crowns (D6750 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

March 24, 2021.
You asked the Plan to waive the copayment for the primary care office visit. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for primary care visits. You have been asked to pay a $10 copayment for the primary care office visit. 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 primary care office visit you had on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve articulating elevating leg rests, a seat elevator, and
powered seat elevator attachments for a power wheelchair.
You asked the Plan to pre-approve the power wheelchair features. You say that you require seat lift and the
articulating leg rests. The Plan denied your request. The Plan says they will overturn the power wheelchair, but
not the features that are for convenience.
The Plan must follow Medicare rules. Medicare rules say that articulating leg rests and the seat lift (that is not
just tilt or recline) are not covered. The power options for a seat lift are not covered when the seat lift is not
covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the power wheelchair features have not been met. Therefore, we decided that the Plan does not
have to pre-approve articulating elevating leg rests, a seat elevator, and powered seat elevator attachments for a
power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a Dexcom continuous glucose monitor (CGM)
You asked the Plan to preapprove the CGM. You say that the CGM should be covered. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, or 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 the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a Dexcom continuous glucose monitor (CGM)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) and mandibular partial denture (D5226).
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. The Plan denied your request. The Plan says these services are 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 a maxillary partial denture (D5225) and mandibular partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency diagnostic exam (D0140) provided on June 24, 2021.
You asked the Plan to pay for the dental service. You say that you had an awfully bad toothache that turned out to be an infection. You say that you were referred to this provider due to your abundance of tori. You also say that you do not have a large amount of money to handle multiple dentist or medical bills. The Plan denied your request. The Plan says 1 emergency diagnostic exam is covered per year. The Plan also says that the frequency limit has been exceeded.
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 the service is listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for an emergency diagnostic exam that
you received on June 23, 2021. Therefore, we decided that the Plan does not have to pay for emergency
diagnostic exam (D0140) provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mastectomy sleeve (L8010).
You asked the Plan to pre-approve the mastectomy sleeve. You say that the mastectomy sleeve should be
covered for the treatment of lymphedema. The Plan denied your request. The Plan says the mastectomy sleeve
is a non-covered item.
The Plan must follow Medicare rules. Medicare rules say that mastectomy sleeve (L8010) will be denied as
noncovered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the mastectomy sleeve have not been met. Therefore, we decided that the Plan does not have to
pre-approve mastectomy sleeve (L8010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty walker ((E0148, E0149).
You asked the Plan to pre-approve the heavy duty walker. You say that the standard walker is not wide enough for you. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that a heavy duty walker is covered for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds. You do not meet coverage criteria for your weight. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the heavy duty walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty walker ((E0148, E0149).