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

We decided that the Plan does not have to pre-approve the upper partial denture.
You asked the Plan to pre-approve the upper partial denture. You say that you want to appeal the partial being denied. The Plan denied your request. The Plan says this exceeds the maximum count allowed per period.
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 also have a maximum benefit of one denture every 5 years. The Plan paid for the upper partial denture provided on September 11, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper partial denture
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of torus palatinus (D7472) and removal of torus mandibularis (D7473).
You asked the Plan to pre-approve the removal of torus palatinus (D7472) and removal of torus mandibularis (D7473). You say that you need this procedure in order to get the dental work completed. 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 the
removal of torus palatinus (D7472) and removal of torus mandibularis (D7473).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the prosthesis provided on September 9, 2020.
You asked the Plan to waive the coinsurance for the prosthesis. You say that you cannot afford to pay this 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 20% coinsurance for prosthetic devices and supplies related to prosthetic devices. You have been asked to pay 20% coinsurance for the prosthesis.
Item Code
Allowed Amount
20% Coinsurance
L8030
$273.55
$54.71
L8000
$173.40
$34.68
L8020
$326.74
$65.35
Total:
$154.74
The prosthesis falls within the Prosthetic Devices 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 prosthesis provided on September 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat radiofrequency ablation services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the frequency limitations have been exhausted.
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation is limited to two sessions per rolling twelve months. The records show two sessions of radiofrequency ablation in the last twelve months - the left lumbar levels at L3-4 and L4-5 on April 21, 2021 and the right lumbar levels at L3-4 and L4-5 on March 30, 2021. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat radiofrequency ablation services
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient behavioral health therapy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the outpatient services. You say that you feel that this service should be covered. The provider was getting paid for the services before and you need the services for mental health. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. The requested provider is also a social worker and is not a Medicare qualified mental health care professional.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve outpatient behavioral health therapy to be provided by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion Device Placement Surgery for the
enrollee.
You asked the Plan to pre-approve these services. You say that research, clinical studies, and patient outcomes
support this device. The Plan denied your request. The Plan says that unproven and not medically necessary
procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The Vertiflex device
is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer
found that the enrollee's condition does not meet criteria for these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Vertiflex Superion Device Placement Surgery for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that not having the requested device will impact your
quality of life. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift 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 stair lift.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for inpatient mental health services provided
from July 20, 2020, through July 21, 2020.
You asked the Plan to reduce the copayment for inpatient mental health services. You say that the provider said
you would on be responsible for a $90 copayment. The Plan denied your request. The Plan says you have been
charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment each day for days 1-7 of an inpatient mental health hospital stay.
You have been asked to pay a $250 copayment for the first two days of inpatient mental health services, for a
total of $500. Inpatient mental health services fall within the Inpatient Mental Health 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 reduce the copayment for inpatient mental health services provided from July 20,
2020, through July 21, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography, heart, without contrast material,
with quantitative evaluation of coronary calcium (75571).
You asked the Plan to pre-approve quantitative calcium scoring. You say that you are requesting
reconsideration of the previous decision and allow coverage for the CT coronary calcium score. The Plan
denied your request. The Plan says the requested service is not covered under Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of quantitative calcium scoring have not been met. Therefore, we decided that the
Plan does not have to pre-approve computed tomography, heart, without contrast material, with quantitative
evaluation of coronary calcium (75571).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tadalafil 5mg tablets.
You asked the Plan to pre-approve the tadalafil tablets. You say that the enrollee requires this drug for
treatment of enlarged prostate. The Plan denied your request. The Plan says this is an oral drug that cannot be
covered by 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 pre-approve tadalafil 5mg tablets.
Benefits for the tadalafil tablets 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic esophagogastroduodenoscopy
(43235, 43450) rendered on August 30, 2019. We also decided that the Plan does not have to waive the
copayment for an injection with anesthetic agents and/or steroid; transforaminal epidural with imaging
guidance on the lumbar or sacral (64483) rendered from January 29, 2020, to December 14, 2020.
You asked the Plan to waive the copayment for a diagnostic esophagogastroduodenoscopy. You also asked the
Plan to waive the copayment for an injection with anesthetic agents and/or steroid; transforaminal epidural with
imaging guidance on the lumbar or sacral. You say that you wanted to make sure the copayments are correct
because you have never had to pay a $250 copayment before. The Plan denied your request. The Plan says you
were 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 $250
copayment per visit for Medicare-covered ambulatory surgical center and outpatient hospital facility visits.
You have been asked to pay a $250 copayment for a diagnostic esophagogastroduodenoscopy. You also have
been asked to pay a $250 copayment for two dates of services of an injection with anesthetic agents and/or
steroid; transforaminal epidural with imaging guidance on the lumbar or sacral, which is a total of $500 ($250
copayment x 2 dates of service = $500). A diagnostic esophagogastroduodenoscopy and injections with
anesthetic agents and/or steroid; transforaminal epidural with imaging guidance on the lumbar or sacral fall
within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory
Surgical Centers; 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 diagnostic
esophagogastroduodenoscopy (43235, 43450) rendered on August 30, 2019. We have also decided that the
Plan does not have to waive the copayment for an injection with anesthetic agents and/or steroid;
transforaminal epidural with imaging guidance on the lumbar or sacral (64483) rendered on January 29, 2020,
to December 14, 2020
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 the compression stockings are
needed for cellulitis. The Plan denied your request. The Plan says this item is not a covered benefit.
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
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing, 4 or more teeth per quadrant,
(D4341) for all 4 quadrants.
You asked the Plan to pre-approve the dental services. You say that you did not know that you could only have
deep cleanings done every 3 years. You say that your dentist never called you to get your teeth cleaned. You
say that you went somewhere else. You also say that you cannot afford to pay this bill. The Plan denied your
request. The Plan says that scaling and root planing is covered once per quadrant every 3 calendar years. 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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental services have not been met. Specifically, the frequency limit has been exceeded. The
record shows that the Plan paid for scaling and root planing, 1 to 3 teeth per quadrat, (D4342) for all 4
quadrants that you received on February 17, 2020. Therefore, we decided that the Plan does not have to pre-
approve scaling and root planing, 4 or more teeth per quadrant, (D4341) for all 4 quadrants
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you have lymphedema and that is
why the requested DME is needed to help with your circulation. The Plan denied your request. The Plan says
this item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower partial denture (D5226).
You asked the Plan to pre-approve the lower partial denture (D5226). You say that you are unable to chew
without the lower denture. You say that you are unable to pay for this service and you are asking for an appeal
so you can live with dignity. The Plan denied your request. The Plan says the service is not a covered 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.
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 the
lower partial denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid exam and selection provided on August 23,
2021.
You asked the Plan to pay for the hearing aid exam and selection. You say that your doctor told you to go to
this provider for the fitting so you assumed it would be covered. The Plan denied your request. The Plan says
the service was not rendered by a Plan provider.
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 plan's coverage rules apply in this case. The Plan pays for
hearing services only when they are received from the Plan's hearing vendor.
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aid exam and selection have not been met. Therefore, we decided that the Plan does not
have to pay for the hearing aid exam and selection provided on August 23, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on June
23, 2021.
You asked the Plan to waive the copayment for the ambulance trip. You say that your doctor told you it was a
package deal, and you did not expect a separate ambulance charge. 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 $65
copayment for each separate ambulance service.
You have been asked to pay a $65 copayment for the ambulance trip. Ambulance trips fall within the
Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance
transportation provided on June 23, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital visit services provided to the enrollee on January 12, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this provider is not allowed to bill directly.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. The rendering provider is not eligible to bill Medicare. The Plan did not pre-approve the services. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital visit services provided to the enrollee on January 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) injections.
You asked the Plan to pre-approve the Prolia injections. You say that the requested drug is medically
necessary. The Plan denied your request. The Plan says there is a requirement for a trial of zoledronic acid
before Prolia can be approved.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Prolia injections. Our reviewer says
that the requested drug is not considered reasonable and necessary at this time due to step therapy criteria. Our
physician reviewer found the record indicates that the enrollee has age related osteoporosis without
osteoporotic fracture. The requested medication is a new start. The provided records do not indicate that the
enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the
enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one
alternative. The elements of the coverage criteria are not satisfied.
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 Prolia injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve Prolia (denosumab) injections
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts, removable, molded to patient model,
longitudinal/ metatarsal support,
You asked the Plan to pre-approve foot inserts. You say that the medical records provided support the necessity
of the services in dispute. The Plan denied your request. The Plan says the records show that you do not have
diabetes or that the shoe is part of a brace.
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 foot inserts, removable, molded to
patient model, longitudinal/ metatarsal support