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

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from June 10, 2020, to June 17, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that this claim was 
denied and your insurance should pay for it. The Plan denied your request. The Plan says this claim was not 
denied, the enrollee is just being charged the applicable cost sharing for this service.  
 The Plan says that this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $325 copayment per day for days 1-6 for inpatient hospital services.  
 
The enrollee has been asked to pay a $325 copayment per day for days 1-6, for a total of $1950. This means 
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing 
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient hospital services provided from June 10, 2020, to 
June 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT scan of the chest for the enrollee. 
 
You asked the Plan to pay for an additional CT scan of the chest provided to the enrollee.. 
You say that this should be paid for. The Plan denied your request. The Plan says the records submitted are 
duplicates of each other. 
 
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, the CPT Code Manual definition of code 71275 is "Computed tomographic angiography, chest 
(noncoronary), with contrast material(s), including noncontrast images, if performed, and image 
postprocessing." 
 
We find that CPT code 71275 is not supported in the medical record. Specifically, this billing appears to 
represent a duplicate billing. Based on this information, we decided that Medicare rules for coverage of an 
additional CT scan of the chest provided to the enrollee on. have not been met. Therefore, we 
decided that the Plan does not have to pay for CT scan of the chest for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection without guidance. 
 
You asked the Plan to pre-approve a sacroiliac joint injection without guidance. You say that the requested 
sacroiliac joint injection without guidance is medically necessary. The Plan denied your request. The Plan says 
the requested sacroiliac joint injection without guidance is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a sacroiliac joint injection without 
guidance. Our reviewer says that the requested sacroiliac joint injection without guidance is not medically 
necessary. Our physician reviewer found the review indicates that the enrollee is with a history of low back 
pain with radiation to the lower extremities. Sacroiliac joint injections (SIJ) are recommended as an option if 
the patient has failed at least 4-6 weeks of aggressive conservative therapy.  Sacroiliac dysfunction is poorly 
defined and the diagnosis is often difficult to make due to the presence of other low back pathology (including 
spinal stenosis and facet arthropathy). The diagnosis is also difficult to make as pain symptoms may depend on 
the region of the SI joint that is involved (anterior, posterior, and/or extra-articular ligaments).  Pain may 
radiate into the buttock, groin and entire ipsilateral lower limb, although if pain is present above L5, it is not 
thought to be from the SI joint.  Criteria for the use of SIJ blocks include that the patient has had and failed at 
least 4-6 weeks of aggressive conservative therapy including, physical therapy (PT), home exercise and 
medication management. There should be evidence of a clinical picture that is suggestive of sacroiliac injury 
and/or disease. At least three positive exam findings of SI joint dysfunction should be present on physical exam 
such as: Patrick's test, thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test. 
 
 
 
 
In this case, there is no evidence of a clinical picture that is suggestive of sacroiliac injury and/or disease. There 
are not at least three positive exam findings of SI joint dysfunction present on physical exam such as: Patrick's 
test, thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test. The  review has determined that the 
requested sacroiliac joint injection without guidance is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a sacroiliac joint injection without guidance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a sacroiliac joint injection without guidance.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided by a participating 
provider. 
 
You asked the Plan to waive the copayment for lab work. You say that you already paid the specialist copay. 
You say that you do not know why you are receiving an additional bill. The Plan denied your request. The Plan 
says the correct copayment has been applied. 
 
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 $15 
copayment for outpatient diagnostic tests/laboratory tests.  
 
You have been asked to pay a $15 copayment for lab work. When multiple services are provided during an 
office visit, additional copayments can be applied; therefore, the correct copayment has been applied. lab work 
falls within the outpatient diagnostic tests/laboratory tests 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 lab work provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified periodontal procedure (D4999) provided on 
June 18, 2020. 
 
You asked the Plan to pay for the dental service. You say that the treatment you had done was for tooth # 11. 
You say that it was a laser. You say that nowhere in your plan materials does it mention a laser. You also say 
that it should be covered as part of the scaling and root planing that you received, as one service. You also say 
that doing the right thing matters. The Plan denied your request. The Plan says the unspecified periodontal 
procedure is not listed as a covered service. The Plan also says any services not listed 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the unspecified periodontal procedure 
(D4999) provided on June 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the duplex scan and the noninvasive 
physiologic studies you had on June 5, 2020. 
 
You asked the Plan to waive the copayments for the duplex scan and the noninvasive physiologic studies. You 
say that you have had these tests in the past and have never had to pay more than a $40 copayment. The Plan 
denied your request. The Plan says you were charged these copayments correctly.  For the noninvasive 
physiologic study, the allowed amount is less than your copayment obligation, so you are responsible for the 
full 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 $160 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $160 copayment for the duplex scan and the noninvasive physiologic studies. 
The duplex scan and the noninvasive physiologic studies fall within the radiological diagnostic services benefit 
category. This copayment is applied per test. 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 copayments for the duplex 
scan and the noninvasive physiologic studies you had on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on June 2, 2020. 
 
You asked the Plan to pay for the dental service. You say that you waited until the dentist received 
authorization that the crown would be covered before getting it done. You say that you should not be 
responsible as you were advised the service would be covered. The Plan denied your request. The Plan says 
there is an annual maximum of $1,000. The Plan says that the annual maximum has been exceeded prior to this 
date of 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the annual maximum of $1,000 has 
been exceeded. The record shows that the Plan paid $78 for services you received on January 15, 2020, $848 
for services on January 23, 2020, and $74 for services on May 19, 2020. Therefore, we decided that the Plan 
does not have to pay for the crown (D2740) provided on June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation (D0140), the panoramic x-ray (D0330), the extraction (D7230), the first 15 minutes of deep sedation (D9222), the additional15 minutes of deep sedation (D9223), and the therapeutic parenteral drugs (D9612) provided on April 9, 2020.You asked the Plan to pay forthe dental services. You say that you were advised you had a bad infection. You say that you needed a wisdom tooth to be extracted. You also say that you always use your insurance ID card for dental services and have never had an issue.The Plan denied your request. The Plan says the provider in this case is not contracted with the Plan. The Plan says that carerendered by a provider that is not part of our supplemental dental network is 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 coveragerules 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 when you receive them out of network.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140), the panoramic x-ray (D0330), the extraction (D7230), the first 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223), and the therapeutic parenteral drugs (D9612) provided on April 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Pegfilgrastim injection.You asked the Plan to pre-approvea Pegfilgrastim injection. You say that the requested Pegfilgrastim injection is medically necessary.The Plan denied your request. The Plan says the requested Pegfilgrastim injection is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Pegfilgrastim injection. Our reviewer says that the requested Pegfilgrastim injection is not medically necessary. Our physician reviewer found the enrollee is with multiple myeloma who is being treated with Cyclophosphamide every 2 weeks, Pomalidomide daily, and Daratumumab, Dexamethasone and Xgeva.  His absolute neutrophil count dropped to 400. There is no documented history of neutropenic fever. There is no documentation that the dose or schedule of Cyclophosphamidecannot be altered. This reviewer also notes the enrollee is taking daily Pomalidomide which is also a myelosuppressive drug.  The recommended use of Pegfilgrastim is for administration not between 14 days before and 24 hours after administration of cytotoxic chemotherapy. (FDA label per FDA website.) Therefore the requested use carries additional risk for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof a Pegfilgrastim injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea Pegfilgrastim injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ankle orthosis you received on July 16, 
2020. 
 
You asked the Plan to waive the coinsurance for the ankle orthosis. You say that since you got this orthosis at 
an urgent care facility, there should be no cost sharing. The Plan denied your request. The Plan says you were 
charged this coinsurance 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 20% 
coinsurance for prosthetic devices and related supplies (including braces).  
 
You have been asked to pay 20% coinsurance for the ankle orthosis. The ankle orthosis falls within the 
prosthetic devices and related supplies (including braces) 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 ankle orthosis you received on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forevaluation, testing and programming adjustment of defibrillator with analysis, review and report, dual lead defibrillator system (93283) provided on February 4, 2020 and July 21, 2020.You asked the Plan to waive the copayments forevaluation, testing and programming adjustment of defibrillator with analysis, review and report, dual lead defibrillator system. You say that you do not believe you should be responsible for the copayment.The Plan denied your request. The Plan says the cost share is correct.The rules say a plan must disclose to its enrollees inclear, 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 Outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay two (2) $10 copayments for evaluation, testing and programming adjustment of defibrillator with analysis, review and report, dual lead defibrillator system. This service falls within the Outpatient diagnostic tests and therapeutic services and 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 copayments forevaluation, testing and programming adjustment of defibrillator with analysis, review and report, dual lead defibrillator system (93283) provided on February 4, 2020 and July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) and the 
fillings (D2392 x 2) provided on June 26, 2020. 
 
You asked the Plan to pay for the dental services. You say that this was the first time that you had scaling and 
root planing for this quadrant. You say that fillings are covered "unlimited per plan year." You say that the 
provider is in network with your plan. You also say that these services should be covered. The Plan denied your 
request. The Plan says there is an annual maximum benefit of $1,000 for covered dental services. The Plan says 
that the maximum benefit has been exhausted. The Plan also says that the provider in this case was in network 
at their old location, but is not in network at their new location. 
 
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 regardless of the provider's 
network status, the maximum allowance of $1,000 has been exhausted. The record shows that the Plan paid 
$436.50 for the dental services you received on January 11, 2020, $342 for services received on February 25, 
2020, and $221.50 for services received on March 17, 2020, totaling $1,000 and thus exhausting your annual 
benefit. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing 
(D4341) and the fillings (D2392 x 2) provided on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a post and core in addition to a crown (D2952) for tooth #7. 
 
You asked the Plan to pre-approve the dental service. You say that this should be covered. The Plan denied 
your request. The Plan says post and core in addition to a crown is not listed as a covered 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. 
 
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 
post and core in addition to a crown (D2952) for tooth #7.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve out of network dietician services. 
 
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested 
provider. The Plan denied your request. The Plan says this provider is out of network. 
 
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 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 out of 
network dietician services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), 
and the unspecified preventive procedure (D1999) provided on June 9, 2020. 
 
You asked the Plan to pay for the dental services. You say that the benefit booklet says that dental cleanings, x-
rays, etc. are covered in and out of network. You say that a plan representative advised that the claim was 
processed out of network and that is the set amount for the services. You also say that this information is not in 
your benefit book The Plan denied your request. The Plan says the provider in this case is not a network 
provider. The Plan says that you may still be billed by an out of network provider for any amount greater than 
the MAC payment made by the plan to the provider. The Plan also says the unspecified preventive procedure is 
not listed as a covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you may be billed more by an out of 
network provider if the charge is greater than MAC. You are responsible for all fees in excess of the allowed 
amount for services received from an out of network provider. Additionally, the unspecified preventive 
procedure is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120), prophylaxis (D1110), and the unspecified preventive procedure (D1999) 
provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 11 extractions (D7140) provided on July 28, 2020. 
 
You asked the Plan to pay for the dental services. You say that your teeth have been breaking apart at the gum 
for several years. You also say that you need the assistance that the plan promised. You also say that you work 
2 part time jobs just to get by. The Plan denied your request. The Plan says extractions are not listed as a 
covered 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. 
 
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. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the 11 extractions (D7140) provided 
on July 28, 2020.