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

 
We decided that the Plan does not have to pay for the fluoride tray provided on February 24, 2020. 
 
You asked the Plan to pay for the fluoride tray. You say that you believe this service should be covered. The 
Plan denied your request. The Plan says fluoride treatments are not covered under your supplemental dental 
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. Fluoride trays are directly treating the teeth to prevent decay, and the 
fluoride treatment itself is dental in nature. Therefore, we decided that the Plan does not have to pay for the 
fluoride tray provided on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
and drugs or medicaments dispensed in the office for home use (D9630) provided on January 16, 2020. 
 
You asked the Plan to pay for the bone replacement graft and drugs or medicaments. You say that the services 
were medically necessary. 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 bone 
replacement graft for ridge preservation (D7953) and drugs or medicaments dispensed in the office for home 
use (D9630) provided on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the medical equipment and supplies you 
received on February 24, 2020. 
 
You asked the Plan to waive the coinsurance for the medical equipment and supplies. You say that you 
shouldn't have to pay this amount because you only had the items for a month and could not return them earlier 
due to COVID-19. You also said that you were dissatisfied with the customer service you received. 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 durable medical equipment and supplies.  
 
You have been asked to pay 20% coinsurance for the medical equipment and supplies. 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. This amount applies regardless of 
whether or not you are satisfied with the service you received. Please note that the Plan is handling your issue 
regarding date of service March 3, 2020 in a separate case. Therefore, we decided that the Plan does not have to 
waive the coinsurance for the medical equipment and supplies you received on February 24, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a SPECT scan of the brain. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not have an indication for this test. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested imaging is medically reasonable and necessary. Our physician reviewer found the NCD does not 
explicitly and specifically exclude SPECT imaging in the evaluation of patients with parkinsonian signs and 
symptoms. SPECT imaging is a valid tool in the differential diagnosis of Parkinson's disease and non-
degenerative tremors, and has been shown to aid in early and differential diagnosis. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
a SPECT scan of the brain.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 11, 2018. 
 
You asked the Plan to pay for the lab services. You say that the test was medically necessary in determining the 
best course of treatment. The Plan denied your request. The Plan says the time limit for filing has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until April 9, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on July 11, 2018.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multilevel lumbar fusion (22612, 22585, 22614, 22558). 
 
You asked the Plan to pre-approve multilevel lumbar fusion. You say that this should be covered. The Plan 
denied your request. The Plan says this 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 multilevel lumbar fusion. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient does not meet criteria for multilevel fusion surgery. There is no 
documentation of flexion and extension x-rays showing more than 5mm of abnormal motion at all of the 
proposed operative fusion levels. Instability of the spine at each level has not been established. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of multilevel lumbar fusion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve multilevel lumbar fusion (22612, 22585, 22614, 22558).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care on February 2. 
2019 provided by an out-of-network provider. 
 
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you were assured by the 
admitting department of the hospital that you were covered. The Plan denied your request. The Plan says the 
claim was processed accordingly with your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received inpatient hospital care on February 2. 2019 by an out-of-network 
provider. You are asked to pay 50% coinsurance for the out-of-network inpatient hospital care. Your EOC 
states that enrollees must pay 50% of the total cost per out-of-network inpatient hospital care stay. 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 inpatient hospital care on February 2. 2019 provided by an out-of-
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve complete maxillary denture. You say that you received a temporary upper 
denture in March 2019. You also say that this denture no longer fits. The Plan denied your request. The Plan 
says the benefit allowance for this service has been met. 
 
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, maxillary dentures are limited to one 
of codes D5110, D5130, D5211, D5213, or D5225 per 60 months. The record shows that you received an 
immediate denture on March 29, 2019 and your maxillary dentures benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 29 
to February 5, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the inpatient hospital 
stay was the result of the hospital's error during an earlier stay. 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 $275 
copayment for days 1-5 of each time you are admitted to an acute care hospital.  
 
You have been asked to pay $1,375, or a $275 copayment for days 1-5, for an inpatient hospital stay. An 
inpatient hospital stay falls within the "Inpatient hospital 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 an inpatient hospital stay from January 29 to February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral occlusal x-ray (D0240) provided on February 5, 
2020. 
 
You asked the Plan to pay for the intraoral occlusal x-ray (D0240). You say that they took two x-rays of the 
same tooth when only one is paid for. You say that it is not your fault and you shouldn't have to pay. 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 pay for the 
intraoral occlusal x-ray (D0240) provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facet joint injection (64492) provided on February 11, 
2020. 
 
You asked the Plan to pay for the injection. 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 the 
service billed. 
 
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 64492 is injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary 
procedure).  
 
We asked our coder 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 the injection. Our reviewer says that CPT code 64492 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report includes 
injections made at levels C3, C4, and, C5, which supports two facet joint blocks.  Therefore CPT 64492 cannot 
be verified as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pay for a facet joint injection (64492) provided on February 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
January 22, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received outpatient surgery services provided on January 22, 2020. You are 
asked to pay a $50 copayment for the services. Your EOC states that enrollees must pay a $50 copayment for 
Medicare-covered outpatient surgery in an ambulatory surgical center. 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 outpatient surgery services provided on January 22, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 18, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 physician services provided to the enrollee on March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation (D0140), intraoral x-ray 
(D0220) and re-cement or re-bond crown (D2920) provided on February 10, 2020. 
 
You asked the Plan to pay more for the limited oral evaluation (D0140), intraoral x-ray (D0220) and re-cement 
or re-bond crown (D2920). You say that the Plan paid $85 leaving an unpaid amount of $157. You say that the 
Plan should pay the remaining balance. The Plan denied your request. The Plan says the claim processed 
correctly. 
 
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 is only obligated to pay the 
allowed amount for your covered dental services. You are responsible for the amount greater than the payment 
made by the plan for dental services from an out-of-network provider.  
 
Service Billed Amount Allowed 
Amount 
Plan Paid Difference of 
Billed & Allowed 
Amount 
Member 
Liability 
Oral Evaluation $84 $33 $33 $51 $51 
Intraoral X-Ray $32 $11 $11 $21 $21 
Recement/Rebond 
Crown 
$126 $41 $41 $85 $85 
TOTAL:     $157 
 
  
 
Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation (D0140), intraoral 
x-ray (D0220) and re-cement or re-bond crown (D2920) provided on February 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have Train-of-Four neuromuscular junction testing (95937) provided March 
13, 2020. 
 
You asked the Plan to pay for neuromuscular junction testing. You say that the charges billed are the 
neuromonitoring services requested by the surgeon as he felt these services were medically necessary during 
the procedure performed on this day. The Plan denied your request. The Plan says it is not appropriate to bill 
separately for train of four monitoring. 
 
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, we have confirmed that code Train-
of-Four monitoring has a bundled relationship with the code 95861 (intraoperative neuromonitoring of 
electromyography (EMG) or motor evoked potentials (MEP)) and cannot be paid as billed. This code cannot be 
paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for neuromuscular junction testing (95937) provided 
March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the osteogenesis device provided on January 
9, 2019. 
 
You asked the Plan to waive the cost share for the provided device. You say that you were told the device 
would be covered. The Plan denied your request. The Plan says the cost share was applied based on your in-
network benefits. 
 
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% of 
the Medicare-allowed amount for durable medical equipment and related supplies.  
 
You have been asked to pay 20% of the Medicare-allowed amount for the provided device. The device falls 
within the durable medical equipment 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 cost share for the osteogenesis device provided on January 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oroantral fistula closure, two extractions (D7210 and 
D7140), each subsequent 15-minute increment of intravenous moderate (conscious) sedation/analgesia, and 
guided tissue regeneration provided on December 19, 2019. 
 
You asked the Plan to pay for the oroantral fistula closure, extractions, intravenous moderate 
sedation/analgesia, and guided tissue regeneration. You say that you feel these procedures were as much of a 
medical one as a dental one, due to the illness, infection, and bone loss. The Plan denied your request. The Plan 
says these services are dental in nature and are not covered by the medical plan. The Plan also says that your 
medical plan does not include supplemental dental coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the oroantral fistula closure, two 
extractions (D7210 and D7140), each subsequent 15-minute increment of intravenous moderate (conscious) 
sedation/analgesia, and guided tissue regeneration provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D3330, D6740, D6245). 
 
You asked the Plan to pre-approve the services. You say that there is justification for this request. The Plan 
denied your request. The Plan says this is a benefit exclusion. 
 
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. Therefore, we decided that the Plan does not have to pre-approve 
dental services (D3330, D6740, D6245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the elbow protector (E0191). 
 
You asked the Plan to pre-approve the orthotic device. You say that using the elbow protector is a cheaper 
alternative to other treatments. The Plan denied your request. The Plan says the orthotic device is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that orthotic devices include rigid and semi-rigid 
devices which are used to support or correct a weak or deformed body part. The guidelines were not met 
because there is no indication the requested orthotic is rigid or semi-rigid.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the elbow protector (E0191).