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

 
We decided that the Plan does not have to pay for the bone replacement graft (D4263) and guided tissue 
regeneration (D4266) provided. 
 
You asked the Plan to pay for the bone replacement graft (D4263) and guided tissue regeneration (D4266). 
You say that the infection got worse and you rushed for treatment. You say that this should be covered as 
emergency treatment. The Plan denied your request. The Plan says the services are not covered 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. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft (D4263) and guided tissue regeneration (D4266) provided.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay fornon-transport ambulance services (A0998) received on April 10, 2020.You asked the Plan to pay fornon-transport ambulance services. You say that you should not be charged for the ambulance merely arriving and checking your vitals.The Plan denied your request. The Plan says rules for coverage have not been met.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 April 10, 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 fornon-transport ambulance services (A0998) received on April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for epidural steroid injection. 
 
You asked the Plan to pay for epidural steroid injection. 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 medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered for 
certain 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 pay for epidural steroid injection. Our reviewer says 
that the documentation does not support that the requested services are medically reasonable or necessary. Our 
 
 
physician reviewer found the enrollee had an MRI that showed facet joint hypertrophy at multiple levels 
causing neuroforminal stenosis.  There is no documentation of Physical therapy, Chiropractic therapy or other 
conservative therapies. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pay for epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence provided showing that the enrollee suffers from deterioration, 
decline, or any changes in chronic that may require skilled nursing care. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found additional skilled 
nursing services are not required to effectively provide treatment, care, and/or services in order to improve your 
condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent 
deterioration. You have had no recent significant changes in your conditions or medications.  
 
 
 
You have been educated in disease management. Your skin is intact without complex wound care needs. You 
do not require the ongoing skills of a professional nurse. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-participating 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 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 by 
an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) rendered on April 1, 2020 to 
April 2, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a PC/TC indicator of 4 represents global test only 
codes. 
 
We looked at the file and Medicare rules. The billed code 93000 has a PC/TC indicator of 4 and cannot be 
billed in the inpatient hospital setting. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
electrocardiogram (EKG) rendered on April 1, 2020 to April 2, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on January 13, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you have never had a 
copayment that high. 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 $110 
copayment for emergency care.  
 
You have been asked to pay a $110 copayment for an emergency room visit. An emergency room visit falls 
within the emergency 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 
emergency room visit provided by a participating provider on January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental pathology services provided on June 11, 2020. 
 
You asked the Plan to pay for the dental pathology services. 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 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 dental pathology services 
provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis provided on June 3, 2020. 
 
You asked the Plan to pay for the prophylaxis. You say that you will be getting a knee replacement that will 
interfere with your second cleaning. You say that you know cleanings are covered twice a year. The Plan 
denied your request. The Plan says a cleaning is only allowed once every six months. 
 
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, you also have a maximum benefit of 
one cleaning every 6 months. The Plan paid for a cleaning provided on January 6, 2020, which exhausted your 
benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
March 5, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you understand that this service 
is only covered once every three years. You also say that your previous dentist sold his practice to another 
dentist that did not accept your insurance. The Plan denied your request. The Plan says this service exceeds the 
frequency limitation in your benefit plan. 
 
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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on January 23, 2018, and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D testing rendered on March 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
  
The test at issue in this appeal, Vitamin D testing, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the Vitamin D testing rendered on March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and the implant 
supported crown (D6065). 
 
You asked the Plan to pay for the dental services. You say that you contacted the Plan in March. You say that 
you were advised that implant crowns were covered. You also say that the dentist contacted the Plan and was 
also advised that the implants would be covered. The Plan denied your request. The Plan says there is no record 
of the provider calling them to confirm benefits. The Plan says there is no record of you calling to confirm 
benefits. The Plan says custom fabricated abutment is not listed as a covered service. The Plan also says that 
implant supported crowns are not listed as a covered service. 
 
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. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment 
(D6057) and the implant supported crown (D6065).  
 
Your complaint about being misinformed by a plan representative is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a respiratory assist device (E0470) and a 
humidifier (E0562) received on January 7 to March 7, 2020. 
 
You asked the Plan to waive the coinsurance for a respiratory assist device and a humidifier. You say that his 
cost-share has increased compared with previous charges. The Plan denied your request. The Plan says the 
correct coinsurance 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 20% 
coinsurance for each Medicare-covered item of durable medical equipment.  
 
You have been asked to pay $34.37 per month, or 20% coinsurance of the Plan-allowed amount of $171.84, for 
a respiratory assist device, and $4.03 per month, or 20% coinsurance of the Plan-allowed amount of $20.16, for 
a humidifier. A respiratory assist device and a humidifier fall within the "Durable medical equipment (DME) 
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 coinsurance for a respiratory assist 
device (E0470) and a humidifier (E0562) received on January 7 to March 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on April 14, 2020. 
 
You asked the Plan to pay for the durable medical equipment. 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. 
 
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 for the supplies provided in this case for date of service 
April 14, 2020. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
provided on April 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the eyeglasses purchased on February 14, 2020. 
 
You asked the Plan to reimburse for the eyeglasses. You say that you are requesting reimbursement of the 
eyeglasses. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. Review of the file show that you purchased the eyeglasses on 
February 14, 2020. The Plan paid $125 for the glasses which exhausted your benefit. Therefore, you are 
responsible for the remainder of the bill. Your EOC states, for Vital plan members, if the eyewear you purchase 
costs more than $125, you pay the difference. Therefore, we decided that the Plan does not have to reimburse 
for the eyeglasses purchased on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reimbursement for non-covered service code 99203. 
 
You asked the Plan to pay for these services. You say that these services should be covered. The Plan denied 
your request. The Plan says these services are not covered under the Plan benefit. 
 
The Plan must follow Medicare rules. Medicare has limited coverage for acupuncture. Your Plan has limited 
coverage for acupuncture. As such, the Plan?s rules apply in this case. The services billed in this case are not 
covered under acupunctures benefit. Therefore, we decided that the Plan does not have to pay for 
reimbursement for non-covered service code 99203.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthetic nerve block provided for post-operative pain 
control on November 20, 2019, billed with code 64450-XU-LT. 
 
You asked the Plan to pay for the nerve block. You say that these injections were ordered by the surgeon for 
postoperative pain control and should be covered. The Plan denied your request. The Plan says the 
documentation does not indicate the type/name of the block performed. As such, this 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 64450 is Injection(s), anesthetic agent(s) and/or steroid; 
other peripheral nerve or branch. 
 
We find that CPT code 64450 is not supported in the medical record. Specifically, although a second local 
anesthetic injection on the left leg is documented, it does not specify the nerve or branch being injected. 
Without documentation of the nerve injected, it cannot be confirmed that this is a separately identifiable block 
from the femoral nerve block which was also billed. Based on this information, we decided that Medicare rules 
for coverage of the nerve block have not been met. Therefore, we decided that the Plan does not have to pay for 
the anesthetic nerve block provided for post-operative pain control on November 20, 2019, billed with code 
64450-XU-LT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Unna boot strapping provided to the enrollee on April 4, 
2018. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says while the debridement was paid, the Unna boot strapping was billed incorrectly per 
Medicare guidelines. 
 
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 this service was not filed until August 2, 2019, which is the date the waiver 
of liability was signed to make it valid appeal. More than one calendar year from the date of service had passed 
before a claim was filed. The Plan paid a portion of this claim but was not required to do so by Medicare. 
Therefore, we decided that the Plan does not have to pay for Unna boot strapping provided to the enrollee on 
April 4, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $45 copayment charged for specialist services provided on 
April 28, 2020. 
 
You asked the Plan to waive this copayment. You say that you should not have to pay $45 for a 15 minute 
phone call. The Plan denied your request. The Plan says this copayment is a contractual obligation. 
 
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 $45 
copayment for specialist services.  
 
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 $45 copayment charged for specialist services provided on April 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay you had from 
March 5, 2020, through March 6, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this copayment should 
be waived because while in the hospital, you were tested for COVID-19. You said that your tests came back 
negative and you were diagnosed with pneumonia and the flu. The Plan denied your request. The Plan says you 
were charged this copayment correctly because you were not admitted to the hospital for COVID-19. 
 
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 $350 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $350 copayment per day for days 1-5 for the inpatient hospital 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 copayment for the inpatient hospital stay you had from March 5, 2020, through 
March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to charge outpatient out of network rehabilitation therapy provided 
from February 14, 2019, to March 21, 2019 at the in-network rate. 
 
You asked the Plan to charge these services at the in-network rate. You say that you called and enacted the 
passport feature of your contract and should only be charged the in-network rate. The Plan denied your request. 
The Plan says enacting the passport allows coverage but does not include coverage at the in-network rate. 
 
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 $70 
copayment for outpatient rehab visits. 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 charge outpatient out of network rehabilitation therapy 
provided from February 14, 2019, to March 21, 2019 at the in-network rate.