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

 
We decided that the Plan does not have to pay the full amount for the dental consultation (D9310) and 2 simple 
extractions (D7140) provided from June 29, 2020, to July 24, 2020. 
 
You asked the Plan to pay the full amount for the dental services. You say that you were referred for the 
extractions. You say that you were advised that the consultation would be covered minus the copay that you 
paid. You also say that you should be reimbursed the $116 that you already paid for the consultation. The Plan 
denied your request. The Plan says dental consultations are excluded from coverage. The Plan says the 
extractions were processed correctly. The Plan also says extractions have a 50% coinsurance. 
 
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 dental consultation is not among 
those covered under this benefit. Additionally, simple extractions have a 50% coinsurance. This is a contractual 
obligation you agreed to when you enrolled in the Plans dental coverage. Therefore, we decided that the Plan 
does not have to pay the full amount for the dental consultation (D9310) and 2 simple extractions (D7140) 
provided from June 29, 2020, to July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that you lost your dentures. You also say that you 
cannot eat without them. The Plan denied your request. The Plan says dentures are limited to 1 set every 5 
years. The Plan says you last received dentures less than 5 years ago. The Plan says that the frequency limit has 
been reached. 
 
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 and partial dentures are a covered 
service, the frequency limit of 1 set every 5 years has been reached. The record shows that the Plan paid for 
partial dentures that you received on September 26, 2017, thus exhausting the benefit. Therefore, we decided 
that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on July 17, 2020. 
 
You asked the Plan to pay for eyeglasses. You say that this item should be covered. The Plan denied your 
request. The Plan says you exceeded your maximum benefit allowed for this service. 
 
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. The Plan covers up to a total of $300 every 12 months for eyeglasses, frames, lenses or contact lenses 
from participating network providers. 
 
We looked at the file and the Plan's rules. You have exceeded your maximum benefit for this service. Based on 
this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for eyeglasses provided on July 17, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services received on May 1, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says that the services received are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that a claim for the services received was not provided 
with the case file. In addition, the plan states that these services are not payable, however, does not state why. 
In addition, the plan did not show that the services were received or referred to by an out of network provider. 
Therefore, we decided that the Plan has to pay for the laboratory services received on May 1, 2019.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MRI of the brain (70551) provided on June 17, 2020. 
 
You asked the Plan to pay for the MRI of the brain. You say that you would like reconsideration because this 
service was billed correctly. The Plan denied your request. The Plan says the manifestation cannot be the only 
or primary diagnosis code on the claim. 
 
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 70551 is not supported in the record. Specifically, the diagnosis code listed on the claim 
is F02.80. Per Medicare, this diagnosis code has a 'code first' note indicating that the underlying condition 
should be sequenced first. Based on this information, we decided that Medicare rules for coverage of the MRI 
of the brain have not been met. Therefore, we decided that the Plan does not have to pay for MRI of the brain 
(70551) provided on June 17, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 18, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be 
submitted to Original Medicare. 
 
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 
physician services provided to the enrollee on March 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency transportation: mini-bus, mountain area 
transports, or other transportation systems (CPT Code A0120). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says this facility in non-participating and it is across state lines. The Plan states the VA 
Health systems supply their own transportation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. 
 
 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have not been met. This facility in non-participating 
and it is across state lines. The Plan states the VA Health systems supply their own transportation and your 
covered benefits do not include transportation to a non-participating facility. Therefore, we decided that the 
Plan does not have to pre-approve non-emergency transportation: mini-bus, mountain area transports, or other 
transportation systems (CPT Code A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided on October 
23, 2019. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is a bundled 
procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a 
procedure are considered a component part of a comprehensive code. 
 
IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered 
integral to the performance of IONM services. As such, this component of the procedure is included in 
payment for the overall IONM monitoring service which was already paid. No separate payment can be made 
for this part of the service. Therefore, we decided that the Plan does not have to pay for the train of four testing 
(CPT 95999) provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown and core buildup, including any pins when 
required. 
 
You asked the Plan to pre-approve the crown and core buildup. You say that you were advised that you require 
a crown, but the service is not covered. The Plan denied your request. The Plan says these services are not 
covered under the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown and core buildup, including any pins when required.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on February 6, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you were never told 
it would cost this much. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $3,488.32. The total amount you are being asked to pay is $697.66 ($3,488.32 x 20% = 
$697.66). Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on 
February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four 2D oral/facial photographic images, oral hygiene 
instructions, two localized deliveries of antimicrobial agents, periodontal procedure, and additional intraoral 
periapical x-ray provided. 
 
You asked the Plan to pay for the 2D oral/facial photographic images, oral hygiene instructions, localized 
deliveries of antimicrobial agents, periodontal procedure, and additional intraoral periapical x-ray. You say that 
it is difficult to establish a baseline with a new dentist without x-rays being taken. The Plan denied your 
request. The Plan says 2D oral/facial photographic image, oral hygiene instructions, localized delivery of 
antimicrobial agents, and periodontal procedure are not covered benefits. The Plan also says that your benefits 
for the additional intraoral periapical x-ray have been satisfied and the frequency limitation has been exceeded. 
 
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, 2D oral/facial photographic image, 
oral hygiene instructions, localized delivery of antimicrobial agents, and unspecified periodontal procedure are 
not among those covered under this benefit. The contract also clearly states that intraoral x-rays are limited to 
one procedure per calendar year. The record shows that you received two additional intraoral periapical x-rays, 
one of which was covered by the Plan, and your intraoral x-rays benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pay for the four 2D oral/facial photographic images, oral 
 
 
hygiene instructions, two localized deliveries of antimicrobial agents, periodontal procedure, and additional 
intraoral periapical x-ray provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 1, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the testing is 
not a Medicare benefit for the diagnoses listed on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the 
documentation in the beneficiary's medical documentation 
 
We find that the testing at issue is not supported in the medical record. In this case, there are insufficient 
medical records to show that the results of this testing will be used to determine a specific diagnosis or 
treatment strategy. This testing is not covered for screening purposes. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the lab services provided on July 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the charges for the outpatient surgery and related hospital 
services provided from February 13, 2020, to February 14, 2020, and the inpatient hospital care provided from 
February 18, 2020, to February 20, 2020. 
 
You asked the Plan to reduce the charges for the outpatient surgery and subsequent inpatient admission. You 
say that you feel that you are being billed for these services incorrectly. The Plan denied your request. The Plan 
says it was decided to make payment for the self-administered drugs provided during your outpatient hospital 
stay. However, all the other charges were correctly applied as your copayment for the services 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 $395 
copayment for outpatient surgery in a hospital setting and a $395 copayment per day for inpatient hospital care. 
 
You have been asked to pay a $395 copayment for the outpatient surgery and two daily $395 copayments for 
the subsequent inpatient admission. 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 reduce the charges for the outpatient surgery 
 
 
and related hospital services provided from February 13, 2020, to February 14, 2020, and the inpatient hospital 
care provided from February 18, 2020, to February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring feature/device coded A9279 provided on 
January 23, 2020. 
 
You asked the Plan to pay for the monitoring feature/device. 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 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. 
 
In this case, the CPT Code Manual definition of code A9279 is monitoring feature/device, stand-alone or 
integrated, any type, includes all accessories, components and electronics, not otherwise classified. 
 
We find that CPT code A9279 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for 
coverage of the monitoring feature/device have not been met. Therefore, we decided that the Plan does not 
have to pay for the monitoring feature/device coded A9279 provided on January 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nivolumab (Opdivo) for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough proof in medical studies that this medication will help more than 
other treatments. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found per compendia sources, 
second line Opdivo is approvable only for squamous cell cancer. The enrollee has adenocarcinoma. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nivolumab (Opdivo) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reclast (J3489). 
 
You asked the Plan to pre-approve Reclast. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation showing the enrollee could not be treated with oral 
bisphosphonates. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Reclast. Our reviewer says that Reclast 
is not indicated in this case. Our physician reviewer found the use of anabolic therapy was recommended for 
treatment of the enrollee's severe osteoporosis; however, the enrollee declined due to a needle phobia. As such, 
bisphosphonates would be the appropriate initial therapy. There is no indication that the enrollee has 
contraindications to the use of oral bisphosphonates; therefore the documentation does not support that Reclast 
is medically reasonable or necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Reclast have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Reclast (J3489).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
May 7, 2020, to June 4, 2020. 
 
You asked the Plan to pay for the SNF services. You say that the enrollee needed SNF care. The Plan denied 
your request. The Plan says 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs and no identifiable skilled therapy service needs. In addition, the beneficiary does not require 
skilled nursing or therapy services on a daily basis and does 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided from May 7, 2020, to June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on November 27, 2019. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
services cannot be verified. 
 
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 looked at the file and the rules. We find that CPT codes are not supported in the medical record. The 
records do not indicate the time spent for the services provided. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the critical care services provided on November 27, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the emergency room services provided on June 
20, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you were not aware of the copay 
responsibility. The Plan denied your request. The Plan says there are no exceptions to the cost share. 
 
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 
copay for emergency care.  
 
You have been asked to pay a $50 copay for the services provided. The services fall 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 copay for the emergency room services 
provided on June 20, 2020.