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

We decided that the Plan does not have to pre-approve a posterior fixed bridge for teeth # 2, 3, 4,and 5.
You asked the Plan to pre-approve the dental services. You say that you have already lost the tooth in front.
You say that you have pain from your gum to your jaw. You say that your gum keeps bleeding and you are
unable to eat. The Plan denied your request. The Plan says that fixed bridges for posterior teeth 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. The Plan covers the dental
services 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 dental services. Our reviewer says
that the service is not medically necessary. Our physician reviewer found although the treatment plan may be
reasonable, it is not a covered service under the Plan. Given the fact the tooth to be replaced is a posterior
tooth, and no exceptions are applicable, there is no medical necessity for the requested procedure.
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 the dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve a posterior fixed bridge for teeth # 2, 3, 4,and 5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a raised toilet seat, grab bars, mattress topper and seat lift 
mechanism provided on March 12, 2020 through April 7, 2020. 
 
You asked the Plan to pay for the supplies. You say that you would like reconsideration because you were 
informed that this equipment was necessary. The Plan denied your request. The Plan says the documentation 
does not support that qualification of reasonable and necessary criteria for a seat lift mechanism as detailed in 
the LCD are met. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare will pay for durable medical equipment that 
is mainly used to serve a medical purpose.  
 
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 supplies. Our reviewer says that based on 
the medical records provided there is no documentation that you meet the LCD criteria for a seat lift 
mechanism. 
 
Additionally, the raised toilet seat, grab bars and mattress topper are non-covered benefits as they do not serve 
a strictly medical purpose.  
 
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 supplies have not been met. Therefore, we decided that the Plan does not 
have to pay for a raised toilet seat, grab bars, mattress topper and seat lift mechanism provided on March 12, 
2020 through April 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient mental health care provided by 
a participating provider on March 9, 2020 to March 13, 2020. 
 
You asked the Plan to waive the copayment for an inpatient mental health care. You say that you were 
supposed to get an MRI but because of Covid-19 you could not get it done. 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 $325 
copayment per day for days 1-5. There is a $0 copayment for days 6-90 for inpatient mental health care.  
 
You have been asked to pay a $325 copayment per day for days 1-4 for an inpatient mental health care stay. 
The total amount you are being asked to pay is $1,300 ($325 x 4 days = $1,300). An inpatient mental health 
stay falls within the inpatient mental health 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 mental health care provided by a participating provider on March 9, 2020 to March 
13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from December 
20 to December 27, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you don't have the funds 
to pay this bill. 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 $285 
copayment for each day of days 1-7 of each inpatient stay.  
 
You have been asked to pay $1,995, or a $285 copayment for each day of days 1-7, 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 December 20 to December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-ray services received on March 30, 
2020. 
 
You asked the Plan to pay for the office visit and x-ray services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered 
benefit when provided by a chiropractor. 
 
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 office visit and x-ray services received on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 19, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the office visit (99204). You say that you would like reconsideration because the 
member has an extended medical history with comorbidities. The Plan denied your request. The Plan says the 
provider did not obtain prior authorization and this service was not urgent or emergent. 
 
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 medical services provided on December 19, 
2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nasal/sinus endoscopy services coded 31276 and 31255 
provided on March 2, 2020. 
 
You asked the Plan to pay for the nasal/sinus endoscopy 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 31276 and 31255 are not supported in the medical record. Specifically, the operative 
report did not include documentation of a surgical nasal/sinus endoscopy, with frontal sinus exploration, 
including removal of tissue from frontal sinus, when performed; therefore, code 31276 cannot be verified. In 
addition, the operative report did not include documentation of a total (anterior and posterior) nasal/sinus 
endoscopy, surgical with ethmoidectomy; therefore, code 31255 cannot be verified. Based on this information, 
we decided that Medicare rules for coverage of the nasal/sinus endoscopy services have not been met. 
Therefore, we decided that the Plan does not have to pay for the nasal/sinus endoscopy services coded 31276 
and 31255 provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital analysis of an electroencephalogram (95957) provided 
on September 3, 2019 through September 5, 2019. 
 
You asked the Plan to pay for the digital analysis. 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 95957 is digital analysis of electroencephalogram (EEG) 
(eg, for epileptic spike analysis).  
 
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 digital analysis. Our reviewer says that CPT code 95957 
does not meet criteria for billing or reimbursement consideration. Our reviewer found the records do not show 
any spikes to analyze, therefore it is inappropriate to report CPT 95957. 
 
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 digital analysis have not been met. Therefore, we decided that the Plan does 
not have to pay for digital analysis of an electroencephalogram (95957) provided on September 3, 2019 
through September 5, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for train of four testing (95999) provided on July 29, 2019. 
 
You asked the Plan to pay for train of four testing. You say that these services were underpaid. The Plan denied 
your request. The Plan says this service is no separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 
95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not 
a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. 
Based on this information, we decided that Medicare rules for coverage of train of four testing have not been 
met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on July 
29, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9502) provided on January 9, 2020 
through January 15, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code S9502 has a status code of I 
which is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9502 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9502 has a status indicator of I. This means that CPT code S9502 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9502) 
provided on January 9, 2020 through January 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for botulinumtoxin-A (Botox) provided on 
December 5, 2019. 
 
You asked the Plan to waive the coinsurance for Botox. You say that you usually only pay a $125 copayment 
and this cost-share is wrong. The Plan denied your request. The Plan says the coinsurance amount 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 20% 
coinsurance for Botox. The allowed amount of this Botox is $895.40, resulting in a coinsurance obligation of 
$179.08. 
 
You have been asked to pay 20% coinsurance for Botox. Botox falls within the Medicare Part B Prescription 
Drugs 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 coinsurance for botulinumtoxin-A (Botox) 
provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial foot, shoe inserts provided on June 13, 2019. 
 
You asked the Plan to pay for the shoe inserts (L5000). You say that the inserts were medically necessary. The 
Plan denied your request. The Plan says the records submitted did not include documentation to support that 
the replacement of this brace was necessary due to loss or irreparable damage. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that J. Avery had L5000 inserts provided from a different provider on October 17, 2017, at the 
time the shoe inserts (L5000) were received from you. The L5000 inserts provided from a different provider on 
October 17, 2017 serve the same purpose as the shoe inserts (L5000) at issue. The orthoses are still within the 
5-year RUL and the documentation submitted does not show that the orthoses are irreparably worn, irreparably 
damaged, or that the enrollee had a change in medical condition to warrant the orthoses at issue. Based on the 
records provided, there is no indication the orthoses provided met Medicare coverage criteria for replacement 
at the time of issue. Therefore, we decided that the Plan does not have to pay for the partial foot, shoe inserts 
provided on June 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two pontics and two retainer crowns provided on 
February 4, 2020. 
 
You asked the Plan to pay for the pontics and retainer crowns. You say that the Plan approved these services in 
2019 saying they would pay for them. You also say that the Plan did not inform you that your benefits changed 
until it was too late. The Plan denied your request. The Plan says these services are not included on your 
benefit plan. The Plan also says that you received an Annual Notice of Changes in October 2019 that showed 
prosthodontics were not listed under the benefits for 2020. 
 
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 two 
pontics and two retainer crowns provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment defined by codes L0650, 
L1851, L1971, L2397, L3170, L3916, L3960 provided to the enrollee on March 23, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. 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. 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 proof of delivery to support medical necessity for the supplies provided in 
this case. The documentation submitted did not include an itemized shipping/billing invoice to indicate the 
specific supplies. 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 durable medical equipment 
defined by codes L0650, L1851, L1971, L2397, L3170, L3916, L3960 provided to the enrollee on March 23, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery and hospitalization services received on 
April 9, 2019. 
 
You asked the Plan to pay for surgery and hospitalization services received. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are 
not medically necessary. 
 
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 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 surgery and hospitalization services received. Our reviewer says that the documentation does not support that the services received were 
medically reasonable or necessary. Our physician reviewer found it appears that you had recurrence of a 
meningioma, for which you sought care, as that is where you had her initial surgery. The provided 
care was foreseen and, therefore, not urgent. While the provided care was medically necessary, it was not 
emergent. Therefore, the received out of network, out of area care is not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgery and hospitalization services received have not been met. 
Therefore, we decided that the Plan does not have to pay for surgery and hospitalization services received on April 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care services rendered on March 
10, 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 $40 
copayment for each office visit to other providers for urgently needed services.  
 
Review of the file shows that you received urgent care services on March 10, 2020. You have been asked to 
pay a $40 copayment for these services. These services fall within the office visit to other providers for 
urgently needed services 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 urgent 
care services rendered on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a visual field assessment (0379T) 
provided on April 7, 2019 through April 1, 2020. 
 
You asked the Plan to waive the copayments for the visual field assessment. You say that you would like 
reconsideration because this service has been paid in full in the past. The Plan denied your request. The Plan 
says these claims were processed correctly according to your EOC. 
 
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 Medicare covered vision services rendered in 2019 and a $45 copayment for Medicare covered 
vision services rendered in 2020.  
 
You have been asked to pay a $35 copayment for Medicare covered vision services rendered in 2019 and a $45 
copayment for vision services rendered in 2020. 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 copayments for a 
visual field assessment (0379T) provided on April 7, 2019 through April 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pay  for the  ambulance  services  provided  by EMS on May 17, 2020.You asked the  Plan to pay  for the  ambulance  services.  You say  that you're  requesting  to reconsider  the  denial of payment  for  the  treatment  you received.The  Plan  denied  your  request.  The  Plan  says these  services  are not a covered  benefit.The  Plan  must  follow  Medicare  rules.  The  rules  say that  Medicare  does not pay  for ambulance  services  when there  is  no transport. The  ambulance  company  did not  provide  transport  services  on May  17, 2020. The ambulance  benefit  is  a transportation  benefit.  When  there  is no transport,  neither  Medicare  nor the  Plan  pays  for the  services  provided.Therefore,  we decided  that  the Plan  does not have to pay for the ambulance  services  provided  by EMS on May  17, 2020.