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

We decided that the Plan has to pre-approve the periodontal scaling and root planing for the lower left and lower right quadrants. We decided that the Plan does not have to pre-approve the periodontal scaling and root planing for the upper left and upper right quadrants.
You asked the Plan to pre-approve the periodontal scaling and root planing for the lower left and lower right quadrants. The Plan says that the periodontal scaling and root planing is not medically necessary for the lower left and lower right quadrants. The Plan also says that the frequency limit has been exceeded for the upper left and upper right quadrants.
We decided that the Plan has to pre-approve the periodontal scaling and root planing for the lower left and lower right quadrants.
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. The Plan covers periodontal scaling and root planing when the services are medically necessary and reasonable. 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 periodontal scaling and root planing for the lower left and lower right quadrants. Our reviewer says that the periodontal scaling and root planing for the lower left and lower right quadrants is medically necessary. Our physician reviewer found based on the documentation that was provided, the periodontal scaling and root planing for the lower right and left quadrants meets the criteria for coverage. However, due to the frequency limitations, periodontal scaling and root planing for the upper right and left quadrants does not meet the criteria for coverage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root plaing for the lower left and lower right quadrants have been met. Therefore, we decided that the Plan has to pre-approve the periodontal scaling and root planing for the lower left and lower right quadrants.
We also decided that the Plan does not have to pre-approve the periodontal scaling and root planing for the upper left and upper right quadrants. Though the Plan offers a dental benefit in excess of Medicare coverage and the requested service is listed as covered, the frequency limit has been reached. The record shows that the Plan previously paid for periodontal scaling and root planing for the upper left and upper right quadrants on October 7, 2019. Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing is for the upper left and upper right quadrants.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the low-level laser treatments coded as S8948 and the vertebral axial decompression coded as S9090. We decided that the Plan does not have to pay for the MSM Organic Sulfur.
You asked the Plan to pay for the low-level laser treatments coded as S8948 and the vertebral axial decompression coded as S9090. You say that you have tried many other treatments but this treatment regimen was the only one to help you and was able to help you avoid a high cost surgery. You feel that this should be covered by the Plan as it is a cost savings from the approved surgery. The Plan says that the spinal manipulations, office visits and physical therapy treatments were approved and paid. However, codes S8948, S9090, and A9153 are not covered by Medicare or your supplemental benefit.
We decided that the Plan has to pay for the low-level laser treatments coded as S8948 and the vertebral axial decompression coded as S9090.

The Plan follows Medicare rules. Medicare rules say that plans must clearly and accurately describe all benefits covered under the Plan. The contract indicates that non-Medicare covered chiropractic may be covered including medically necessary therapy when provided in conjunction with the visit specifically for spinal or joint adjustment. In this case, we find that the contract does not clearly indicate the services covered under the plan. The services described by S8948 and S9090 could reasonably fall into the medically necessary therapy category. No medical records were requested to allow for a determination on medical necessity. Based on this, we find that the rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for the low-level laser treatments coded as S8948 and the vertebral axial decompression coded as S9090.
We also decided that the Plan does not have to pay for the MSM Organic Sulfur.
The Plan follows Medicare rules. Medicare rules say that OTC items are not covered. Your supplemental chiropractic benefit does not include coverage for OTC supplements. In this case, the Organic Sulfur is available without a prescription and is considered OTC. This is not covered by Medicare nor your Plan. As such, the sales tax associated with this product is also not covered. Therefore, we decided that the Plan does not have to pay for the MSM Organic Sulfur.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build up (D2950) and endodontic therapy (D3330).You asked the Plan to pre-approvecore build up (D2950) and endodontic therapy (D3330). You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested 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 dental codes, D2950 and D3330 are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecore build up (D2950) and endodontic therapy (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins (D2950) on teeth 4 and
30.
You asked the Plan to pre-approve the core buildup. You say that there is not enough supporting teeth structure
remaining to hold or retain resin restoration. Full coverage crown is needed. The Plan denied your request. The
Plan says this service is not covered under the plan 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. Services not listed on the
benefits chart are not covered by the plan.
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 core
buildup, including any pins (D2950) on teeth 4 and 30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical tooth extractions (D7210), the fixed partial denture sectioning (D9120), and the additional dental service (D9999) rendered by the out of network (OON) dental provider on November 21, 2019.
You asked the Plan to pay for these services. You say that you incorrectly believed that you were referred to a dental provider that was in network. The Plan denied your request. The Plan says that they will not pay for the services you receive from an out of network dentist.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the case file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Specifically, the services were provided by an out of network dentist. Therefore, we decided that the Plan does not have to pay for the surgical tooth extractions (D7210), the fixed partial denture sectioning (D9120), and the additional dental service (D9999) rendered by the out of network (OON) dental provider on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) rendered by the out of network 
(OON) provider on February 19, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99213) rendered by the out of network (OON) provider on February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the lab services provided on January 22, 
2020. 
 
You asked the Plan to waive the deductible for the lab services. You say that these lab services were medically 
necessary so they should be paid. The Plan denied your request. The Plan says you had not yet met your 
deductible when these services were rendered. 
 
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 $500 
deductible before the Plan will start to pay for your care.  
 
You have been asked to pay a $500 deductible toward the lab services. You had not yet met this annual 
deductible at the time you had these lab services, which is why you are being billed for these services. 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 deductible for the lab services provided on January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on 
February 26, 2020.      
 
You asked the Plan to pay for the knee orthosis (L1851 LT), and suspension sleeve (L2397 LT). You say that 
the orthoses were medically necessary. The Plan denied your request. The Plan says the documentation 
submitted did not indicate the provider discussed the need for the billed supply code, therefore the billed supply 
code cannot be verified. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order, valid proof of delivery, or relevant medical records which 
support medical necessity for the supplies provided in this case. There are no medical records, around the date 
of the order, supporting medical necessity for the orthosis. The physician order is for one right orthosis and one 
right sleeve. The claim is for left side orthoses. The delivery ticket included left and right side orthoses. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided 
on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit (G0439), administration of 
pneumococcal vaccine (G0009), pneumococcal conjugate vaccine (90670), annual depression screening 
(G0444), and the visual acuity screening (99173) rendered by the out of network (OON) provider on March 27, 
2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
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 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 annual wellness visit (G0439), administration of pneumococcal vaccine (G0009), 
pneumococcal conjugate vaccine (90670), annual depression screening (G0444), and the visual acuity 
screening (99173) rendered by the out of network (OON) provider on March 27, 2020.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance services provided on January 4, 2020. 
 
You asked the Plan to pay for ambulance services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the patient was hemodynamically stable with stable vital signs. The Plan states the 
patient could have been safely transported by another type of motor vehicle, possibly a van transport vehicle 
and there is a CPT-code modifier (-GY) for ambulance / emergency medical services response without 
transport. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient?s health. The Plan follows the same rules.  
 
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 ambulance services. Our physician reviewer 
found given the age of patient and the refractory nature of blood sugar this was necessary and reasonable for 
ambulance transport. Blood sugar unable to be lowered with therapy can be the result of a more serious 
underlying problem.  Given the age of patient and nature of this problem, the transport by ambulance was 
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 ambulance services have been met. Therefore, we decided that the Plan has to 
pay for ambulance services provided on January 4, 2020.  
 
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 August 7, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on August 7, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on April 18, 2019. 
 
You asked the Plan to pay for lab tests. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken 
in an office setting, therefore the Place of Service (POS) code 81 ? indicating an independent laboratory setting 
? is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of 
lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on April 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for open treatment of distal radial intra-articular fracture or 
epiphyseal separation; with internal fixation of 3 or more fragments (CPT Code 25609) provided on January 
15, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Per CMS claims processing manual guidelines, surgical technicians are not listed as a health care practitioner 
that can report modifier AS. The services of a surgical technician assisting at surgery are included in the 
reimbursement to the facility and not separately reimbursable." Current Procedural Terminology (CPT) code 
25609 AS LT (1 Unit) remains not supported. The submitted medical records indicate that the services were 
performed by a Registered Nurse First Assistant (RNFA). Although skilled, an RNFA is not recognized for 
payment by CMS. Of note, per CMS/Medicare guidelines, the services of Surgical Technicians and RN First 
Assists (RNFA) are not eligible for separate reimbursement. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal 
fixation of 3 or more fragments (CPT Code 25609) provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body (D6010) provided on 
April 27, 2020. 
 
You asked the Plan to pay for the surgical placement of implant body (D6010). You say that you thought you 
would be given a little more coverage. 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 
surgical placement of implant body (D6010) provided on April 27, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for eye procedures provided on September 25, 
2019. 
 
You asked the Plan to pay for the anesthesia for eye procedures. You say that the enrollee has coverage for a 
Medicare Advantage Plan only. You also say that the eligibility file shows that the enrollee is eligible. The Plan 
denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare 
covered services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the anesthesia for eye procedures provided on September 25, 
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for train of four monitoring (95937) provided on October 14, 
2019. 
 
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 records indicate that train of four 
testing/monitoring was performed which does not meet the CMS guidelines of CPT code 95937. 
 
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 CMS guidelines of CPT code 95937. Additionally, train of four monitoring is considered integral to the 
primary neuromonitoring procedure and not separately reimbursable. 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 October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and the electrocardiogram (93000) 
rendered by the out of network (OON) provider on May 26, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
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 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 office visit (99214) and the electrocardiogram (93000) rendered by the out of 
network (OON) provider on May 26, 2020.