Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional units muscle skin graft services coded 15734 
and the adjacent tissue transfer or rearrangement services coded 14001 provided on March 17, 2020. 
 
You asked the Plan to pay for the muscle skin graft services and the adjacent tissue transfer or rearrangement 
services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the services billed are not supported by the documentation. 
 
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 codes 15734, 15734-51, 14001, and 14001-51 are not supported in the medical record. 
Specifically, the operative report did not include documentation of a muscle, myocutaneous, or fasciocutaneous 
flap of the trunk; therefore, code 15734 cannot be verified. In addition, the operative report did not include 
documentation of an adjacent tissue transfer or rearrangement, of the trunk; therefore, code 14001 is not 
supported. 
Based on this information, we decided that Medicare rules for coverage of the muscle skin graft services and 
the adjacent tissue transfer or rearrangement services have not been met. Therefore, we decided that the Plan 
does not have to pay for the additional units muscle skin graft services coded 15734 and the adjacent tissue 
transfer or rearrangement services coded 14001 provided on March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation, bitewing x-ray and 
unspecified preventive procedure on May 20, 2020. 
 
You asked the Plan to pay for the prophylaxis, periodic oral evaluation, bitewing x-ray and unspecified 
preventive procedure. You say that your benefits did not say in-network providers only. You say that the claim 
should be covered. 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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis, periodic oral evaluation, bitewing x-ray and unspecified preventive procedure on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, bone replacement graft for ridge preservation, 
problem focused limited oral evaluation, oral surgery procedure, and sales tax provided on April 30, 2020. 
 
You asked the Plan to pay for the extraction, bone replacement graft, problem focused limited oral evaluation, 
oral surgery procedure, and sales tax. You say that you were unaware that this provider had opted out of 
Medicare. The Plan denied your request. The Plan says the treating provider opted out of Medicare on January 
12, 2013. The Plan also says that payment is unable to be made for services provided by a dentist that has opted 
out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the extraction, bone replacement graft for ridge preservation, problem focused limited oral evaluation, oral 
surgery procedure, and sales tax provided on April 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the semi-electric hospital bed, power wheelchair, wheelchair 
accessory, and canister provided on March 8, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the semi-electric hospital bed, power wheelchair, wheelchair accessory, and 
canister. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the services rendered are not a covered benefit. 
 
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 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 semi-electric hospital bed, power wheelchair, 
wheelchair accessory, and canister provided on March 8, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Part B injectable drugs you received 
on May 26, 2020. 
 
You asked the Plan to waive the coinsurance for the drugs. You say that you cannot go to the doctor or use 
home health services to get these drugs, so you should not have to pay. 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 Medicare-covered Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Part B drugs you received. This means that you have been 
asked to pay the correct amount based on your contract with the Plan and applies regardless of where you get 
Part B drugs. 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 Part B injectable drugs you 
received on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on February 4, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that these services were provided with the clear understanding that they would be covered by your 
insurance. You also say that the provider confirmed that these services would not result in any out of pocket 
costs for you. The Plan denied your request. The Plan says these services exceed 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, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation and complete series of intraoral x-
rays on April 10, 2018, and your comprehensive oral evaluation (D0150) and complete series of intraoral x-
rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on February 
4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Denosumab injection (J0897)  therapeutic, prophylactic, or 
diagnostic injection; subcutaneous or intramuscular (96372) provided November 22, 2019. 
 
You asked the Plan to pay for the injection services. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says there is insufficient 
documentation to corroborate the services to confirm Medicare coverage has been met. 
 
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  is not supported in the medical record. Specifically, the records do not indicate that 
Denosumab injection was administered and does not support that therapeutic, prophylactic, or diagnostic 
injection; subcutaneous or intramuscular was performed. Based on this information, we decided that Medicare 
rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not 
have to pay for Denosumab injection (J0897)  therapeutic, prophylactic, or diagnostic injection; subcutaneous 
or intramuscular (96372) provided November 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper interim partial denture (D5820) provided on April 
8, 2020. 
 
You asked the Plan to pay for the upper interim partial denture (D5820). You say that your dentist told you a 
partial needed to be done. You say that it should be covered because it was needed. 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 interim partial denture is not 
considered a standard permanent denture to be covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for the upper interim partial denture (D5820) provided on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on April 27, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that these tests were ordered by a physician. You say that you 
would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior 
authorization was not obtained. The Plan says that the member's primary care physician did not refer these 
services. 
 
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 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 lab work provided on April 27, 2020 by an out of 
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Hizantra infusions you received in the 
home from November 27, 2019 through April 29, 2020. 
 
You asked the Plan to waive the coinsurance for Hizantra infusions. You say that you do your own infusion at 
home and that this drug should be covered in full after meeting your deductible. 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 Medicare-covered Part B drug.  
 
You have been asked to pay 20% coinsurance for Hizantra infusions. According to your Evidence of Coverage, 
unless the infused drug you receive is designated as a HI drug in your Formulary, it is considered a Medicare 
Part B drug for which 20% coinsurance is due. Hizantra is not designated as a HI drug in your Formulary. 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 Hizantra infusions you received in the home from 
November 27, 2019 through April 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical dental implant placement (D6010), custom 
abutments (D6057), cast metal crowns (D6062), and bone grafts (D6104). 
 
You asked the Plan to pre-approve surgical dental implant placement, custom abutments, cast metal crowns, 
and bone grafts. You say that you cannot afford to pay for dental services yourself. 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 pre-approve 
surgical dental implant placement (D6010), custom abutments (D6057), cast metal crowns (D6062), and bone 
grafts (D6104).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service coded 81479 provided on December 
23, 2019. 
 
You asked the Plan to pay for the laboratory service. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the laboratory service coded 
81479 provided on December 23, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay from 
March 11, 2020 to March 31, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that these services were approved. The 
Plan denied your request. The Plan says the copayment 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 a $0 
copayment per day for days 1-20, and a $178 copayment per day for days 21-100 for each SNF stay.  
 
You have been asked to pay a $178 copayment for day 21 of your SNF stay from March 11, 2020 to March 31, 
2020. SNF stays fall within the Skilled Nursing Facility (SNF) 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 a skilled nursing facility (SNF) stay from March 11, 2020 to March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for train of four monitoring (95937) provided on February 13, 
2020. 
 
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support that this code was performed. 
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We find that CPT code 95937 is not supported in the record. Specifically, train of four monitoring does not 
meet Medicare criteria for code 95937. Additionally, train of four monitoring is considered integral toe the 
primary neuromonitoring procedure and separate payment may not be made. Based on this information, we 
decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we 
decided that the Plan does not have to pay for train of four monitoring (95937) provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on May 1, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with this 
copayment. 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 $35 
copayment for physician/practitioner services/in-network/professional services/specialist.  
 
You have been asked to pay a $35 copayment for a specialist office visit. The correct copayment has been 
applied to the services that were provided. A specialist office visit falls within the physician/practitioner 
services/in-network/professional services/specialist 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 by a participating provider on May 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 17, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the medical services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request 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 Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided on March 17, 2020 by an out of network 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on February 13 - 
February 15, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the records provided support that the 
inpatient admission was medically necessary. The Plan denied your request. The Plan says the records provided 
support that the inpatient admission was medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee did not appear to have any signs or symptoms of COPD exacerbation. 
An EKG, negative troponin, and clear GI symptoms suggested nonspecific abdominal pain, which imaging and 
tests suggested did not warrant additional treatment or testing. The enrollee's vitals were stable. Therefore, 
without supportive evidence, it appears that the admitting physician did not reasonably expect that the 
enrollee's necessary hospital care would span at least two midnights. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on February 13 - February 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 13, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 and the referring provider are not network providers with the Plan. The Plan 
did not pre-approve the laboratory services. 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 laboratory services provided on 
December 13, 2019.