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

 We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950).  You asked the Plan to pre-approve core buildup. You say that this service is medically necessary. 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 core buildup, including any pins when required (D2950).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Nexletol for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the plan does not cover outpatient prescription drugs.  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 Nexletol for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213).  You asked the Plan to pre-approve an upper partial denture. You say that a new denture is necessary in order to add an additional tooth. 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 an upper partial denture once per 60 minutes.   We looked at the file and Medicare rules. The Plan provided documentation showing that an upper partial denture was previously covered on December 6, 2018. Based on this information, we decided that the Plan's frequency limit for coverage of an upper partial denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the resin-based composite (D2392) and crown (D2740) provided on April 1, 2021.  You asked the Plan to pay more for the resin-based composite and crown. You say that when you received these services the office advised that they needed a $500.00 payment up front for them. The Plan denied your request. The Plan says the coinsurance was applied correctly according to the benefits of the Plan. The Plan also says that the dental office contacted the Plan on March 31, 2021 and inquired about coverage for a crown and core build-ups, the office was informed that these services were covered under your plan with a 50% co-insurance.  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, you are responsible for a 50% for fillings and crowns. Therefore, we decided that the Plan does not have to pay more for the resin-based composite (D2392) and crown (D2740) provided on April 1, 2021.   Your complaint about your issues with the provider's receptionist 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a manual wheelchair.  You asked the Plan to pre-approve a manual wheelchair. 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. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.   Records show that a manual wheelchair is being requested for use in a long term care facility. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on July 24, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you feel the copayment is too high. 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 $90 copayment for each emergency room visit.   You have been asked to pay a $90 copayment for the ER visit. ER visits fall within the Emergency Care 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 emergency room (ER) visit provided on July 24, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided from April 18, 2021, to April 19, 2021.  
You asked the Plan to waive the copayment for the ER visit. You say that you have limited income and need help with the bill. 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 $120 copayment for each emergency room visit.   
You have been asked to pay a $120 copayment for the ER visit. ER visits fall within the Emergency Care 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 emergency room (ER) visit provided from April 18, 2021, to April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bone replacement graft - retained natural tooth - first site in quadrant (D4263) and surgical placement of implant body: endosteal implant (D6010) provided October 20, 2021.  You asked the Plan to pay for the bone replacement graft and endosteal implant. You say that these services were medically necessary. The Plan denied your request. The Plan says these services are 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 pay for the bone replacement graft - retained natural tooth - first site in quadrant (D4263) and surgical placement of implant body: endosteal implant (D6010) provided October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial lower denture (D5214).  You asked the Plan to pre-approve the dental item. You say that your dentures are broken. You say that the prior authorization was wrongly denied. You say that you are not able to eat properly. You also say that you cannot wait 5 years to get a new one. The Plan denied your request. The Plan says dentures are 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 dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a partial lower denture that you received on October 20, 2020. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Proventil inhaler.  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 self-administered drugs are not covered.  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 a Proventil inhaler.   Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair ramp.  You asked the Plan to pre-approve a power wheelchair ramp. You say that the item is 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 a power wheelchair ramp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and a tooth extraction (D7210) provided by an oral surgeon.  You asked the Plan to pre-approve a comprehensive oral evaluation and a tooth extraction. You say that you have a tooth that needs to be extracted as it keeps getting infected. You went to a general dentist, but the dentist will not extract your tooth. You were referred to an oral surgeon. You also say that you feel this extraction should be covered by the Plan as you have coverage for 1 tooth extraction. The Plan denied your request. The Plan says dental services performed by an oral surgeon 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 comprehensive oral evaluation (D0150) and a tooth extraction (D7210) provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a routine eye exam (S0620) and an eye refraction (92015) provided on August 13, 2021. You asked the Plan to pay for a routine eye exam and an eye refraction. 
You say that you had ophthalmic services after having a routine exam previously by another provider. You are requesting reconsideration. The Plan denied your request. 
The Plan says the maximum benefit/allowed amount has been exceeded.  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 contract says that you receive one routine eye exam per calendar year.  We looked at the file and the Plan's rules. The EOC confirm that you receive one routine eye exam per calendar year. The records show you received a routine eye exam on June 1, 2021; therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a routine eye exam and an eye refraction have not been met. 
Therefore, we decided that the Plan does not have to pay for a routine eye exam (S0620) and an eye refraction (92015) provided on August 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the CPAP supplies provided on August 26, 2021.  You asked the Plan to waive the coinsurance for the CPAP supplies. 
You say that you should not have to pay this bill. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for Medicare-covered durable medical equipment.    
You have been asked to pay $37.34 which is 20% of the allowed amount for the CPAP supplies. The allowed amount is $186.71. ($186.71 x 20% = $37.34). The CPAP supplies fall within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the CPAP supplies provided on August 26, 2021.   
Your complaint about the misleading Explanation of Benefits 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 provide coverage for a Flex Card to assist in payment for food and other items.  You asked the Plan to provide coverage for a Flex Card to assist in payment for food and other items. You say that you do not have food coverage and you feel this service should be a covered benefit. The Plan denied your request. The Plan says he Flex Card to assist in payment for food and other items is not covered by Medicare. A Flex Card for food is not described as a supplemental benefit for you, and it is also not considered reasonable and necessary.  The Plan contract does not provide a supplemental Flex Card benefit.  We looked at the file and the Plan's rules. The file shows that the Plan does not provide a supplemental Flex Card benefit. Therefore, we decided that the Plan does not have to provide coverage for a Flex Card to assist in payment for food and other items.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from July 13, 2021, to July 14, 2021.  You asked the Plan to pay for the self-administered drugs. 
You say that you received a bill for your coinsurance. You say that according to your membership paperwork, you do not have coinsurance. You also say that this bill should be paid since the surgery was authorized and provided by in network providers at an in network facility. The Plan denied your request. 
The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. 
The Plan also says the drugs you received are not covered under Medicare 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 pay for the self-administered drugs provided from July 13, 2021, to July 14, 2021.  
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 maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213).  You asked the Plan to pre-approve an upper partial denture. 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 an upper partial denture once per 60 months.   We looked at the file, and Medicare rules. In this case, the Plan provided documentation showing that an upper partial denture was previously covered on April 15, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of an upper partial denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213).
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) and clinical crown lengthening - hard tissue (D4249).  
You asked the Plan to pre-approve a comprehensive periodontal exam and clinical crown lengthening. You say that this repair is necessary for chewing. The Plan denied your request. The Plan says these services are 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 a comprehensive periodontal evaluation - new or established patient (D0180) and clinical crown lengthening - hard tissue (D4249).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).  You asked the Plan to pre-approve a complete upper denture. 
You say that you received your dentures 2 years ago and would like new ones approved. 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 complete upper denture once every five plan years.   We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper denture was previously covered on August 14, 2019. 
Based on this information, we decided that the Plan's frequency limit for coverage of a complete upper denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from May 27, 2021, to June 12, 2021.  
You asked the Plan to waive the copayment for the inpatient stay. You say that you did not realize your copay for these services would be this high, and you cannot afford this bill. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.  
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 $285 copayment for each of the first 7 days of an inpatient stay. There is a $0 copayment for days 8-90.   
You have been asked to pay a $1,995 copayment for an inpatient stay which exceeded 7 days ($285 x 7 = $1,995). 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 inpatient hospital admission and services provided from May 27, 2021, to June 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).  You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. The Plan denied your request. The Plan says these services are not covered under your benefit plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, 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 complete maxillary denture (D5110) and a mandibular partial denture (D5214).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for chromosome analysis; analyze 20-25 cells (CPT code 88264) provided to the enrollee on January 20, 2021.  You asked the Plan to pay for the laboratory service. You say that the service was medically necessary. The Plan denied your request. The Plan says the laboratory services billed by the provider are not payable under the definition of "physician services.  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 laboratory service have not been met. Review of the file shows that the enrollee was inpatient at the hospital during the date of service. The rules say that the applicable payments made under the prospective payment systems are payment in full for all facility or hospital services, as defined in 42 CFR Section 409.10. CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements (as defined in 42 CFR Section (409.3). Therefore, we decided that the Plan does not have to pay for chromosome analysis; analyze 20-25 cells (CPT code 88264) provided to the enrollee on January 20, 2021.