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

 
We decided that the Plan does not have to reimburse you for the implant supported crowns (D6065) for teeth # 
11, 12, 13, 14, and 15 provided. 
 
You asked the Plan to reimburse you for the dental services. You say that your much needed prosthesis is not 
covered by Medicare. You also say that it does not make sense that the services you received are not covered. 
The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says that 
import supported crowns are not listed as a covered service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to reimburse you 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 reimburse you for the 
implant supported crowns (D6065) for teeth # 11, 12, 13, 14, and 15 provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the allergy shots provided on July 17, 2020. 
 
You asked the Plan to pay for the allergy shots. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The file shows that you received allergy shots while out of the 
service area. The file shows that this service was neither emergent nor urgently needed care and was not 
considered to be needed due to an unforeseen illness or condition. Based on this information, we decided that 
Medicare rules for coverage of the allergy shots have not been met. Therefore, we decided that the Plan does 
not have to pay for the allergy shots provided on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 86077) provided on May 3, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says more than one unit of 
this service is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 80677 is 1. You billed 2 units of this code, exceeding the MUE. 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 the services (CPT 86077) provided on May 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom G6 transmitters and sensors. 
 
You asked the Plan to pre-approve Dexcom G6 transmitters and sensors. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Dexcom G6 transmitters and sensors have not been met. Specifically, medical records were not 
provided. Without this documentation, medical necessity is not able to be established. Therefore, we decided 
that the Plan does not have to pre-approve Dexcom G6 transmitters and sensors.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cologuard testing. 
 
You asked the Plan to pre-approve the requested services. You say that you have had blood in your stool. The 
Plan denied your request. The Plan says you need to have more than Cologuard testing. 
 
The Plan follows Medicare rules. Medicare rules say that Cologuard testing is only covered under certain 
medical indications. 
 
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 you have a history of pelvic pain. Your medical records document a family history of 
malignant neoplasm of the stomach. There is no documented change in bowel movements. You are not 
asymptomatic. You have had pelvic pain for several months. The provided medical records do not document 
that the enrollee has satisfied the coverage requirements. Therefore, Cologuard testing is not medically 
necessary and reasonable. 
 
 
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 Cologuard testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for bupivicaine hydrochloride injection (S0200) provided July 
28, 2020. 
 
You asked the Plan to pay for the injection. You say that you were referred for this authorized procedure due to 
excruciating pain  and you don't understand why this is being denied at this time. It was absolutely necessary to 
perform this procedure . The Plan denied your request. The Plan says S codes are temporary codes that 
Medicare does not pay for. 
 
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 doctor's office billed with a code (S0200) that is not payable. The S codes (temporary codes) 
are used to report drugs, services and supplies for which there are no national codes. These codes are not 
payable by Original Medicare (OM). Medicare does not allow payment of this code even if it is medically 
necessary. Contracted providers are prohibited from billing for services that are not approved. The plan has 
confirmed that the provider will not bill for these charges.  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 bupivicaine hydrochloride injection (S0200) provided July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections (64493). 
 
You asked the Plan to pre-approve the facet injections. You say that the injections are medically necessary. The 
Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan follows Medicare rules. Medicare rules say that the injections are not covered when the pain is 
associated with radiculopathy or neurogenic claudication. 
 
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 facet injections. Our reviewer says 
that the injections are not medically necessary. Our physician reviewer found the record shows the enrollee's
pain is associated with radiculopathy. Facet Joint Injections are not indicated in this case. 
 
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 facet injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve facet injections (64493).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids, digital, binaural, BTE (V5261) purchased 
on February 26, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that the hearing aids you purchased out of pocket were 
only $6,198.00 not $19,927.00. You are asking for an appeal as your benefit package says you receive $700 per 
ear every 3 years. The Plan denied your request. The Plan says hearing aids are covered when purchased from 
the designated in-network vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from an in network provider. The health plan contract says that you must 
contact the plan's hearing vendor to access the hearing evaluation and fitting benefits.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids, digital, binaural, BTE (V5261) purchased on February 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) stay from May 8, 2020 to May 20, 2020 and from May 25, 2020 to June 6, 2020.You asked the Plan to pay forthe SNF stay. You say that the SNF care was necessary for the enrollee.The Plan denied your request. The Plan says the rules for SNF care have not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pay for the SNF stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy needs. In addition, the enrollee did not require skilled nursing or therapy services on adaily basis and did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the SNF stay have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) stay from May 8, 2020 to May 20, 2020 and from May 25, 2020 to June 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug tests (G0483) provided on February 20, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for drug tests. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 definitive drug tests (G0483) provided on 
February 20, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee. 
 
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 out of network physician 
services provided to the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you feel that you 
shouldn't be charged when you were being transferred from one facility to another. The Plan denied your 
request. The Plan says you were charged this cost sharing 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 a $250 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 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 copayment for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care (CPT 97035) you received on January 
20, 2020, and February 19, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic care (CPT 97035) you received on January 20, 2020, and 
February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses provided to the enrollee on April 8, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that DME supplies must be 
provided with a proof of delivery. 
 
We find that HCPCS code L0650 is not supported in the medical record. Specifically, required documentation 
pertaining to the proof of delivery of these supplies was not provided. 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 orthoses provided to the enrollee on April 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xiidra eye drops. 
 
You asked the Plan to pre-approve the eye drops. You say that you would like reconsideration because the eye 
drops are medically necessary. The Plan denied your request. The Plan says the eye drops are not covered for 
the member's condition under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Xiidra eye drops.  
 
Benefits for the eye drops 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forfracture treatment (27246) provided on November 5, 2019.You asked the Plan to pay forfracture treatment. You say that this was billed correctly.The Plan denied your request. The Plan says this code is not supported.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 27246 is closed treatment of greater trochanteric fracture, without manipulation.We find that CPT code 27246 is not supported in the medical record. Specifically, a procedure note for this service is not included in the medical records. Based on this information, we decided that Medicare rules for coverage of fracture treatment have not been met.Therefore, we decided that the Plan does not have to pay forfracture treatment (27246) provided on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on February 25, 2020 
and billed under code 86077. 
 
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 code 86077 was not billed in accordance with Medicare National Correct Coding 
Initiative Policy for Medically Unlikely Edits (MUE). The Plan states that CPT 86077 has an MUE value of 1, 
however 2 units were billed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 86077 is 
1. You submitted the claim for 2 units of this code, exceeding the MUE. Based on this information, we decided 
that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services provided to the enrollee on February 25, 2020 and billed under code 86077.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hepatobiliary system imaging rendered 
on June 29, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that the copayment is a financial 
hardship. The Plan denied your request. The Plan says the copayment was applied 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 a $50 
copayment for in-network advanced imaging services in an outpatient hospital.  
 
Review of the file shows that you received hepatobiliary imaging on June 29, 2020. You have been asked to 
pay a $50 copayment for these services. These services fall within the in-network advanced imaging services in 
an outpatient hospital 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 the 
hepatobiliary system imaging rendered on June 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from January 
13, 2019 to January 18, 2019; January 28, 2019 to January 29, 2019; January 31, 2019 to February 1, 2019; 
February 6, 2019 to February 10, 2019. 
 
You asked the Plan to pay for the SNF stay. You say that you needed SNF care. The Plan denied your request. 
The Plan says the rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 pay for the skilled nursing stay. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found there were no identifiable skilled 
nursing or skilled therapy needs. In addition, the beneficiary did not require skilled nursing or therapy services 
on a daily basis and did not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility setting. 
 
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 skilled nursing stay have not been met. Therefore, we decided that the Plan 
does not have to pay for the skilled nursing facility (SNF) stay provided from January 13, 2019 to January 18, 
2019; January 28, 2019 to January 29, 2019; January 31, 2019 to February 1, 2019; February 6, 2019 to 
February 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on June 15, 2020 
and billed under code 99232. 
 
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 was seen in hospital evaluation on June 15, 2020.  The submitted 
documentation supports 1 (one) unit of 99232, which was previously approved and paid. There is no additional 
documentation supporting additional services which are now being billed. Therefore, they remain denied.   
 
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, this claim was previously submitted 
and paid. There is no indication on the second claim in question that this was a separate and distinct service.  
Based on this information, we decided that Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on 
June 15, 2020 and billed under code 99232.