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

We decided that the Plan does not have to pay for the limited oral evaluation provided on November 8, 2019.
You asked the Plan to pay for the limited oral evaluation. You say that both organizations were asked to submit
their claims. You say that you are appealing the denied service. The Plan denied your request. The Plan says
the service is limited to twice per calendar year.
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 Plan also has a maximum benefit
of two oral exams per year. The records show that the Plan covered an oral examination on October 18, 2019
and December 17, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to
pay for the limited oral evaluation provided on November 8, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the cost for the diagnostic radiology service provided on December 27,
2019.
You asked the Plan to waive the cost for the diagnostic radiology service. You say that the claim is being
appealed. The Plan denied your request. The Plan says that you have been charged the correct cost sharing
amount.
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. The plan did not submit the Evidence of Coverage, Explanation of Benefits,
appeal request, claim form, or medical records to support that a diagnostic radiology service was provided.
Therefore, the plan has not shown that the amount you are being asked to pay is correct or justified by the
health plan contract. Therefore, we decided that the Plan has to waive the cost for the diagnostic radiology
service provided on December 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on December 30, 2019.
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 procedure code 95870 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 95870 is needle electromyography; limited study of
muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal,
cranial nerve supplied muscles, or sphincters.
We find that CPT code 95870 is not supported in the medical record. Specifically, there is no documentation
indicating that lower extremity muscles were tested, for which only two units are payable. 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 testing services rendered on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Medtronic 670G continuous glucose monitor (CGM)
transmitter and sensors.
You asked the Plan to pre-approve Medtronic 670G continuous glucose monitor (CGM) transmitter and
sensors. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan
says the requested device is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that only therapeutic CGMs are covered. Medicare
rules also say that only supplies for therapeutic CGMs are covered.
We looked at the file and Medicare rules. Review of the file shows that you are requesting Medtronic 670G
continuous glucose monitor (CGM) transmitter and sensors. The Medtronic CGM does not give you the
opportunity to make diabetes treatment decisions. The Medtronic CGM is considered a non-therapeutic CGM.
Only therapeutic CGMs and supplies for therapeutic CGM are covered. Based on this information, we decided
that Medicare rules for coverage of Medtronic 670G continuous glucose monitor (CGM) transmitter and
sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Medtronic 670G
continuous glucose monitor (CGM) transmitter and sensors.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided from March 1, 2020 through March 11, 2020.
You asked the Plan to waive the copayment for the SNF services. The Plan denied your request. The Plan says that you are liable for cost sharing.
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 $178 copayment for days 21-100 of SNF care. You have been asked to pay a $178 copayment for the SNF services. You were in a SNF from February 19, 2020 through February 29, 2020 and March 1, 2020 through March 11, 2020. The SNF services falls within the days 21-100 of SNF 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 the skilled nursing facility (SNF) services provided from March 1, 2020 through March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel 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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure
code 81479.
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on
January 27, 2020.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the provider's office
obtained a fax from the Plan that showed diagnostic services were covered at 100%. You also say that the
provider's office called to verify this, because they are not in-network, and were again advised that diagnostic
services would be covered at 100%. The Plan denied your request. The Plan says the total liability amount was
applied correctly. The Plan also says that no calls had been received regarding your benefits from any
provider's office.
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, you are responsible for the difference
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for
the periodic oral evaluation and prophylaxis provided on January 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on February 3, 2020.
You asked the Plan to pay for the 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 were billed incorrectly.
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 73600 is radiologic examination, ankle; 2 views.
We find that CPT code 73600 is not supported in the medical record. Specifically, this code was reported
without a required anatomical modifier (LT, RT, or 50). Based on this information, we decided that Medicare
rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to
pay for the x-ray services provided on February 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecfidera.
You asked the Plan to pre-approve Tecfidera. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Tecfidera.
Benefits for Tecfidera 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you are appealing. The Plan denied your
request. The Plan says the denial of authorization for LTACH service is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found as LTACHs and acute care hospitals are licensed to provide the same level of care,
there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute
care hospital until such time as no acute services are required, then be transferred/discharged to a lower level of
care for any ongoing long-term care needs.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room Services provided September 1 to
September 2, 2015.
You asked the Plan to pay for the Emergency Room Services. You say that the claim should be processed and
paid. The Plan denied your request. The Plan says the claim was not paid because the health plan determined
the services at issue were never provided to the member.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that payment for the Emergency Room services is not supported in the medical record. Specifically,
the record shows that through outreach to the enrollee, the health plan determined that the member did not
receive the services at issue and was a victim of identity theft. Based on this information, we decided that
Medicare rules for coverage of the Emergency Room Services have not been met. Therefore, we decided that
the Plan does not have to pay for Emergency Room Services provided September 1 to September 2, 2015.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Technetium tc-99m mertiatide (A9562)
injected on February 25, 2020.
You asked the Plan to waive the coinsurance for the contrast injection. You say that the coinsurance should be
waived. The Plan denied your request. The Plan says the correct cost sharing 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 20%
coinsurance for Part B Drugs and Contrast Agents.
You have been asked to pay a 20% coinsurance for the contrast injection. The contrast injection falls within the
Part B Drugs and Contrast Agents 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
Technetium tc-99m mertiatide (A9562) injected on February 25, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the bladder capacity measurement provided on February 24, 2020.
You asked the Plan to waive the copayment for the bladder capacity measurement. You say that you had the exact procedure before and were not billed for it. You say that you refuse the bill. The Plan denied your request. The Plan says that the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. Covered services include medically-necessary medical or surgical services furnished in a physician's office. The Plan says you must pay $9.79 for the bladder capacity measurement. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the bladder capacity measurement. The bladder capacity measurement is considered a physician service. The records show that an office visit was billed on the same date by the same provider as the bladder capacity measurement. This means that the bladder capacity measurement is covered under the office visit copayment. Therefore, we decided that the Plan has to waive the copayment for the bladder capacity measurement provided on February 24, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-therapeutic continuous glucose monitor supplies.
You asked the Plan to pre-approve the requested items. You say that it is hard for the family to help the
enrollee. The Plan denied your request. The Plan says there is no benefit for continuous glucose monitors or
their supplies if it is non-therapeutic.
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are only covered
under certain medical indications.
We looked at the file and Medicare rules. 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 pre-approve non-therapeutic
continuous glucose monitor supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 13, 2018 by an out
of network (OON) provider.
You asked the Plan to pay for podiatry service. You say that you received payment for other services without
authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because this provider is out-of-network with the Plan and authorization was not obtained.
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 August 13, 2018
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays (D0230x2) provided on February 11,
2020.
You asked the Plan to pay for the additional intraoral x-rays (D0230x2). You say that the provider does accept
your insurance and that you cannot afford the bill. The Plan denied your request. The Plan says you have
exceeded your maximum benefit limit.
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, there is a benefit limit for the intraoral
x-rays. The plan clearly states that only one intraoral x-ray procedure is covered per calendar year. The records
show the Plan paid for one intraoral x-ray procedure on the same date of service, which exhausted the benefit.
Therefore, we decided that the Plan does not have to pay for the intraoral x-rays (D0230x2) provided on
February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic provided on March 5, 2020.
You asked the Plan to pay for the pontic. You say that you were told by a Plan representative that the extra
dental policy would cover two crowns at 70% each per year. The Plan denied your request. The Plan says this
service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pontic
provided on March 5, 2020.
Your complaint about being misled by the Plan 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on January 11, 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 procedure code 99238 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 99238 is hospital discharge day management; 30 minutes
or less.
We find that CPT code 99238 is not supported in the medical record. Specifically, there is no documentation of
a hospital discharge management note for the billed date of service. 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 hospital discharge services rendered on January 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Synvisc-One. Our reviewer says that
the documentation does not support that the enrollee has tried the required drugs. Our physician reviewer found
the enrollee has a diagnosis of Unilateral primary osteoarthritis of the right and left knees. The documentation
does not support that Orthovisc and Monovisc have been tried and failed. The documentation does not support
that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the
enrollee in this case. Therefore, the enrollee does not meet criteria for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care rendered on December
18, 2019.
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 procedure code 99308 is not separately payable.
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the
same specialty must bill and be paid as though they were a single physician.
We looked at the file and Medicare rules. The file shows that a provider within the same physician group
practice submitted a claim for procedure code 99306 for the date of service at issue. The Plan paid for code
99306. Code 99309 is therefore not separately payable. Therefore, we decided that the Plan does not have to
pay for the subsequent nursing facility care rendered on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the prophylaxis and fluoride application provided on
February 13, 2020.
You asked the Plan to fully pay for the prophylaxis and fluoride application. You say that you were not aware
your dentist was not in-network. You say that the rest of the bill should be paid. The Plan denied your request.
The Plan says the claim processed correctly.
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 Plan is only obligated to pay 50%
of the allowed amount for the prophylaxis and fluoride application.
The prophylaxis and fluoride application were received from an out-of-network provider. Therefore, we
decided that the Plan does not have to fully pay for the prophylaxis and fluoride application provided on
February 13, 2020.