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

We decided that the Plan does not have to waive the copayment for Emergency Room services provided April
5, 2020.
You asked the Plan to waive the copayment for the Emergency Room services. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $120
copayment for Emergency Care.
You have been asked to pay a $120 copayment for the Emergency Room services. The Emergency Room
services 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 Emergency Room services provided April 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit received on December 4, 2019.
You asked the Plan to pay for the annual wellness visit. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services received exceeds your benefit limit.
The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12
months.
Review of the file shows that you had an annual wellness visit on December 4, 2019. You previously had a
wellness visit on April 29, 2019 for which the plan approved and paid. The visit on December 4, 2019 was less
than 12 months from your prior annual wellness visit. We looked at the file and Medicare rules. Based on this
information, we decided that Medicare rules for coverage of the annual wellness visit have not been met.
Therefore, we decided that the Plan does not have to pay for the annual wellness visit received on December 4,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the protective restoration provided on February 27, 2020.
You asked the Plan to pay for the protective restoration. You say that at this appointment the provider decided
to do a protective restoration instead of the filling because it was less money. You also say that your provider
thought it would be a better treatment. The Plan denied your request. The Plan says this service 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 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
protective restoration provided on February 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service provided on January 22, 2020.
You asked the Plan to pay for the ambulance service. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says that the provider is submitting the bill to your primary insurer and then they
will consider the bill as secondary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for the ambulance service until the primary insurer has denied the claim for these services. Therefore, we
decided that the Plan does not yet have to pay for the ambulance service provided on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy and prefabricated post and core in
addition to crown provided on January 31, 2020.
You asked the Plan to pay for the endodontic therapy and prefabricated post and core. You say that every time
you go to an in-network dentist, the Plan pays 20%. You also say that the dentist is billing both you and the
Plan for the 20%, and you feel it is double billing. The Plan denied your request. The Plan says these services
are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
endodontic therapy and prefabricated post and core in addition to crown provided on January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you paid for your current orthotics but you will
always have a need to wear them. 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 foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray and panoramic x-ray provided on March
6, 2020.
You asked the Plan to pay for the intraoral x-ray and panoramic x-ray. You say that services you were
promised are being denied. 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 pay for the
intraoral x-ray and panoramic x-ray provided on March 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 12, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 pay for the drug testing rendered on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve NuShield wound care treatment.
You asked the Plan to pre-approve the requested services. You say that the enrollee has wounds on his toes that
are not healing. The Plan denied your request. The Plan says the enrollee continues to have an active infection
and osteomyelitis.
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 requested services. Our physician
reviewer found that the enrollee has a history of a non-healing wounds of the right ankle, foot and great toe. He
completed 6 weeks of IV Vancomycin and continues on oral antibiotics. He is to begin hyperbaric oxygen
therapy. In this case, the enrollee has an active infection that is still undergoing treatment with oral antibiotics
and hyperbaric oxygen therapy. He may require skin grafting. There is no specific clinical rationale for the use
of the requested NuShield. The requested wound treatment is not medically reasonable or necessary to treat the
enrollee at this time.
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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve NuShield wound care treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device
(HFCWOD).
You asked the Plan to pre-approve these services. You say that the device will have an effective outcome for
your condition. The Plan denied your request. The Plan says you do not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.
The record does not show that you have cystic fibrosis, bronchiectasis, or a covered neuromuscular disease.
This means that you do not have a medical condition for which a high frequency chest wall oscillation devise
can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a
high frequency chest wall oscillation device (HFCWOD).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane inj.
You asked the Plan to pre-approve Durolane (J7318). You say that you want the enrollee to be treated with this
drug. The Plan denied your request. The Plan says the health plan states the enrollee has not first tried and had
a contraindication or intolerance to Monovisc and Orthovisc.
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 Durolane (J7318). Our reviewer says
that the drug is not reasonable or medically necessary. Our physician reviewer found under consideration is a
request for Durolane injections as an exception to the Plan's step therapy with preferred viscosupplementation
agents, Orthovisc and Monovisc. There is no evidence that the enrollee has previously tried the requested
Durolane injections, or is currently under treatment with Durolane injections. There is no evidence that the
enrollee has tried and failed the required step therapy drugs. There is no indication in the submitted medical
records that the plan's required drug(s) are likely be less effective and/or likely have adverse effects for this
enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane (J7318) have not been met. Therefore, we decided that the Plan does
not have to pre-approve Durolane inj.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or
heat exchanger (99190) provided on August 7, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger.
You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this
service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger
(99190) provided on August 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion services provided from December 10, 2019 to
January 22, 2020.
You asked the Plan to pay for the infusion services. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says this code is not valid for Medicare purposes.
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 S9328 is home infusion therapy, implanted pump pain
management infusion; administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
We find that CPT code S9328 is not a valid code for Medicare purposes. S codes are unique temporary codes
established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare
uses another code for reporting of, and payment for, these services. Based on this information, we decided that
Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided
that the Plan does not have to pay for the infusion services provided from December 10, 2019 to January 22,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites (codes D2391 and D2392)
provided on March 9, 2020.
You asked the Plan to pay for the resin-based composites. You say that your records show cumulative
payments by the Plan for dental coverage at $524 through February 17, 2020, and therefore your benefit is not
exhausted. The Plan denied your request. The Plan says your annual maximum benefit is exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 annual dental
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are
responsible for the full charges of any additional dental services. The record shows that you met the annual
maximum benefit while processing this claim on March 9, 2020 and your annual maximum benefit has been
exhausted. Therefore, we decided that the Plan does not have to pay for the two resin-based composites (codes
D2391 and D2392) provided on March 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve azathioprine.
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 selfadministered
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 azathioprine.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 3, 2020 by a nonnetwork
provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-network provider without prior authorization.
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 referring provider 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. 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 medical services provided on March 3, 2020 by a non-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for transmitter, external, for use with interstitial continuous glucose monitoring system.
You asked the Plan to pay for transmitters for use with an interstitial continuous glucose monitor (A9277). You say that the enrollee needs the transmitters. The Plan denied your request. The Plan says the CGM is not one of the approved continuous glucose monitors the supplies for it are not approved either.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code A9277 is not covered by Medicare. Specifically, Medicare rules say that this code is not used to bill for supplies used with a covered therapeutic continuous glucose monitor. Based on this information, we decided that Medicare rules for coverage of transmitters for use with a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for transmitter, external, for use with interstitial continuous glucose monitoring system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2330) and scaling in presence
of generalized moderate or severe gingival inflammation (D4346) provided on March 9, 2020.
You asked the Plan to pay for the resin-based composite and scaling. You say that there are not many innetwork
dentists in your area. You also say that you are unemployed and on social security. The Plan denied
your request. The Plan says these services are not covered benefits under your dental 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 pay for the resinbased
composite (D2330) and scaling in presence of generalized moderate or severe gingival inflammation
(D4346) provided on March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve forehead reconstruction (21137) and a rhinoplasty
(30400).
You asked the Plan to pre-approve forehead reconstruction and a rhinoplasty. You say that these services are
medically necessary. The Plan denied your request. The Plan says these services are cosmetic.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are
coverable.
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 forehead reconstruction and a
rhinoplasty. Our reviewer says that the medical records in the case file support that the requested forehead
reconstruction and rhinoplasty are cosmetic procedures, rather than medically necessary/reconstructive. Our
reviewer found the records include a note from the plastic surgeon stating that the enrollee "spent quite a bit of
time showing me pictures of 20-year-old models that she wants to look like." The enrollee feels her forehead is
too prominent, that her brows are still too prominent, her nose is crooked and her cheeks are not right for her.
The enrollee would like to have more facial feminization procedures done. There was facial nerve injury on the
left side, which has improved. There are no photographs in the case file.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of forehead reconstruction and a rhinoplasty have not been met. Therefore, we
decided that the Plan does not have to pre-approve forehead reconstruction (21137) and a rhinoplasty (30400).