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

We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120), crown (D2740), and core build up (D2950) provided from June 16, 2021, to July 20, 2021.
You asked the Plan to pay for the dental services. You say that you had an infected tooth. You say that our dentist advised it needed to be extracted. You say that your bridge had to be removed in order to have your tooth extracted. You also say that the remaining tooth was part of the bridge. The Plan denied your request. The Plan says the fixed partial denture sectioning, crown, and core build up 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 fixed partial denture sectioning, crown, and core build up are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120), crown (D2740), and core build up (D2950) provided from June 16, 2021, to July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on April 30, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that there should be no charge since it could have been done over the phone. 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 $40 copayment for each specialist visit. 

You have been asked to pay a $40 copayment for the specialist office visit. Specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a specialist office visit provided on April 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevator feature (E2300) for a power wheelchair.

You asked the Plan to pre-approve the power seat elevator feature. You say that this feature is medically necessary. The Plan denied your request. The Plan says a power seat elevator is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that power seat elevation (E2300) is non-covered accessory because it is not primarily medical in nature. 

We looked at the file and Medicare rules. This item is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat elevator feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevator feature (E2300) for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage 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 indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular genetic screening panel (81442) provided on March 23, 2021.
You asked the Plan to pay for the cardiovascular genetic screening panel. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the cardiovascular genetic screening panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiovascular genetic screening panel (81442) provided on March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that the enrollee would have a much safer result with light sedation, which can be accomplished with the Vertiflex. The Plan denied your request. The Plan says this is experimental and investigational.

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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87798) provided on August 12, 2020.

You asked the Plan to pay for the laboratory services (87798). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. According to claims history, the specimen was obtained in a Skilled Nursing Facility POS 32. Therefore, we decided that the Plan does not have to pay for the laboratory services (87798) provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0438) or waive the copayment for the specialist visit provided on July 22, 2021.
You asked the Plan to pay for the annual wellness visit and waive the copayment for the specialist visit. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the Plan paid for the annual wellness visit you received on May 24, 2021. The Plan says that Medicare only covers one annual wellness visit per year. The Plan also says you received a specialist visit on July 22, 2021. The Plan says that the correct copayment has applied per your contract with the Plan for the specialist visit.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.
The rules also 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 the specialist visit. You have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner 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 pay for the annual wellness visit (G0438) or waive the copayment for the specialist visit provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on August 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided on August 5, 2021 by an out-of-network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prednisolone acetate, for the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient 'self-administration' (you take it yourself, or your caregiver [not your provider] gives you the drug).
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 prednisolone acetate, for the enrollee.
Benefits for the medication 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 shower chair.  You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.  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 pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided March 11, 2021, and surgical placement of implant body: endosteal implant (D6010) provided April 6, 2021.
You asked the Plan to pay for the panoramic x-ray and endosteal implant. You say that you would like this
service covered. The Plan denied your request. The Plan says the provider who rendered the services has opted
out of Medicare and therefore 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. The Plan covers the panoramic
x-ray and endosteal implant 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 panoramic x-ray and endosteal implant have not been met.
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330)
provided March 11, 2021, and surgical placement of implant body: endosteal implant (D6010) provided April
6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 23, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that laboratories shall not report multiple individual CPT codes describing the component test results. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care office visit provided on August 14, 2021.
You asked the Plan to waive the copayment for office visit. You say that you always pay cost-sharing on the day of the visit. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $13 copayment for primary care office visit. You have been asked to pay $13 copayment for office visit. Office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a primary care office visit provided on August 14, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided August 18, 2021.
You asked the Plan to pay for the periapical x-rays. You say that your Summary of Benefits shows that x-rays are 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 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
intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessory provided on April 28, 2021.  You asked the Plan to pay for pneumatic compression device. You say that the enrollee received services in an ambulatory surgical center and this equipment was issued to the enrollee for use during surgery. The Plan denied your request. The Plan says the denial of payment for this device is correct, because this pneumatic compression device is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that an E0675 pneumatic compression device is not eligible for reimbursement. Medicare rules say that if the base pneumatic compression device is not covered, related accessories are not eligible for reimbursement.  We looked at the file and Medicare rules. This E0675 pneumatic compression device is not covered by Medicare; therefore, the related accessory is also not covered. Based on this information, we decided that Medicare rules for coverage of pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessory provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tetanus vaccine services (90715 and 90471) provided on July 27, 2021.  You asked the Plan to pay for the tetanus vaccine services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a tetanus vaccine is not covered under your Medicare Part B benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine services (90715 and 90471) provided on July 27, 2021.   Benefits for the tetanus vaccine 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 waive the coinsurance for a folding walker provided on May 20, 2021.
You asked the Plan to waive the coinsurance for folding walker. You say that you were told that this would be provided to you for free. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 folding walker. The allowed amount of this claim is $85.69, resulting in a coinsurance amount of $17.13. You have been asked to pay 20% coinsurance for folding walker. Folding walker falls 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 a folding walker provided on May 20, 2021.
Your complaint regarding receiving inaccurate information about the cost-share for this item is considered to
be a grievance. Maximus Federal Services does not have the jurisdiction to address grievances. Please
contact the Plan for more information about your grievance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that your current shower chair is a regular one and broken and you weigh 300 pounds and will need a heavy duty shower chair. 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 pre-approve a shower chair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on July 18, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 18, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on July 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair resin partial denture base, maxillary (D5612) provided August 24, 2021.
You asked the Plan to pay for the upper partial denture repair. You say that you do not understand why this service is not 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 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 repair resin partial denture base, maxillary (D5612) provided August 24, 2021