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

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and the bone 
replacement graft for ridge preservation (D7953) provided on June 19, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services that were provided were due to an 
emergency. You also say that had the services not been provided, a future claim would have been large and 
more extensive. The Plan denied your request. The Plan says guided tissue regeneration is not listed as a 
covered service. The Plan says bone replacement graft for ridge preservation is not listed as a covered service. 
The Plan also says any services not listed 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. 
 
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 guided tissue regeneration 
(D4266) and the bone replacement graft for ridge preservation (D7953) provided on June 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that based on the medical need, it is not safe for the enrollee to travel.The Plan denied your request. The Plan says an IRF admission is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the documentation doesnot support that the enrollee would meet criteria for admission to an acute inpatient rehabilitation facility. Our physician reviewer also found that there is no indication that the enrollee would require skilled rehabilitation in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on 
February 25, 2020. 
 
You asked the Plan to pay for the drug testing. 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 80307 and G0483 are not supported in the medical record. Specifically, the obtained. 
The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained 
in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage 
of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
testing coded 80307 and G0483 provided on February 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need physical therapy and occupational therapy 
at a rehab level of care in order to gain strength prior to returning home. The Plan denied your request. The 
Plan says the medical necessity criteria are not met for admission to acute inpatient rehabilitation. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found 
that there is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer 
also found that the documentation does not indicate that you are medically stable and would be able to tolerate 
therapy at an IRF. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) and gingival 
irrigation (D4921) provided on June 5, 2020. 
 
You asked the Plan to pay for periodontal scaling and root planing (D4341) and gingival irrigation (D4921). 
You say that you told the dental office you only agreed with any service your insurance covers. You say that 
you need the problem resolved. 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 
periodontal scaling and root planing (D4341) and gingival irrigation (D4921) provided on June 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960), a wrist-hand orthosis 
(L3916), an ankle-foot orthosis with stabilizer (L1971, L3170) provided to the enrollee on February 20, 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 does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist 
orthosis (L3960), a wrist-hand orthosis (L3916), an ankle-foot orthosis with stabilizer (L1971, L3170) provided 
to the enrollee on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a portable oxygen system and an oxygen 
concentrator provided from January 9, 2020, to May 28, 2020. 
 
You asked the Plan to waive the coinsurance for a portable oxygen system and an oxygen concentrator. You 
say that you do not use a breathing machine. The Plan denied your request. The Plan says the coinsurance 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 a 20% 
coinsurance for each in-network Medicare-covered item.  
 
The allowed amount of the claims total $701.70, resulting in a coinsurance obligation of $140.34 for a portable 
oxygen system and an oxygen concentrator. A portable oxygen system and an oxygen concentrator 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 portable oxygen system and an oxygen concentrator provided from January 9, 
2020, to May 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a diagnostic laryngoscopy (31575) 
performed on June 4, 2020, and a bronchoscopy (31622) performed on June 25, 2020. 
 
You asked the Plan to waive the copayments for a diagnostic laryngoscopy and a bronchoscopy. You say that 
the enrollee wasn't given any choice of where she would be seen nor told about the higher copayment for these 
services. The Plan denied your request. The Plan says the correct copayments were 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $250 copayment for outpatient surgery services.  
 
The enrollee has been asked to pay a $250 copayment for a diagnostic laryngoscopy and a bronchoscopy. A 
diagnostic laryngoscopy and a bronchoscopy fall within the "Outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayments for a diagnostic laryngoscopy (31575) performed on June 4, 2020, and a 
bronchoscopy (31622) performed on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for right knee genicular nerve block (64454) provided February 
28, 2020. 
 
You asked the Plan to pay for the genicular nerve block. You say that due to the pain the enrollee was 
experiencing, the provider decided it was medically necessary to perform the procedure. You request review of 
the documentation and reprocessing for payment. The Plan denied your request. The Plan says this service is 
not medically reasonable and not medically necessary. The safety and effectiveness of this procedure has not 
been established. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 genicular nerve block. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve ablation are considered investigational 
and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the 
following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a 
treatment following knee replacement; or as a treatment for individuals who are not candidates for knee 
replacement surgery. The review has determined that the requested genicular nerve block is not reasonable or 
necessary. 
 
 
 
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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pay for right knee genicular nerve block (64454) provided February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 92242) provided on February 14, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 92242 is "Fluorescein angiography and indocyanine-
green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation 
and report, unilateral or bilateral". 
 
We asked our coding 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 services. Our reviewer says that the use 
of CPT code 92242 is not supported by the records provided. Our coding reviewer found that the 
documentation did not include imaging for CPT code 92242. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 92242) provided on February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 25, 2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says The Plan says this is an administrative determination for coding and is not based on 
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use 
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
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 claim is missing the main code and identifier required by Medicare. Based on this information, 
we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services provided to the enrollee on March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) and 
incomplete endodontic therapy (D3332) provided on June 30, 2020. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and incomplete endodontic therapy. 
You say that you would like this claim reconsidered for payment. The Plan denied your request. The Plan says 
these services are not covered benefits under your dental 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 pay for the cone 
beam CT capture and interpretation (D0364) and incomplete endodontic therapy (D3332) provided on June 30, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 23675, CPT 76705) provided on August 
14, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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. 
 
In this case, the CPT Code Manual definition of code 23657 is "Closed treatment of shoulder dislocation, with 
surgical or anatomical neck fracture, with manipulation". The CPT Code Manual definition of code 76705 is 
"Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)". 
 
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 services. Our reviewer says that the use 
of CPT codes 23675 and 76705 is not supported by the records provided. Our physician reviewer found that the 
records submitted did not include documentation of CPT 23675 or CPT 76705. 
 
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 pay for the services (CPT 23675, CPT 76705) provided on August 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) device 
(E0730) provided on December 13, 2019. 
 
You asked the Plan to pay for a TENS device. You say that this was medically necessary. The Plan denied your 
request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS is not reasonable and necessary for the 
treatment of chronic lower back pain. 
 
We looked at the file and Medicare rules. The record shows this was ordered to treat lower back pain and the 
enrollee is not enrolled in a clinical study. Based on this information, we decided that Medicare rules for 
coverage of a TENS device have not been met. Therefore, we decided that the Plan does not have to pay for a 
transcutaneous electrical nerve stimulation (TENS) device (E0730) provided on December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient dialysis treatments provided 
from January 1, 2020, to May 1, 2020. 
 
You asked the Plan to waive the coinsurance for outpatient dialysis treatments. You say that you cannot afford 
the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 outpatient dialysis treatments.  
 
You have been asked to pay the total amount of $4,879.60, which is less than the 20% coinsurance for 
outpatient dialysis treatments. Outpatient dialysis treatments fall within the services to treat kidney disease 
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 outpatient dialysis treatments 
provided from January 1, 2020, to May 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment 
supported crown (D6059) provided on June 22, 2020. 
 
You asked the Plan to pay for the custom fabricated abutment (D6057) and abutment supported crown 
(D6059). You say that the procedure was done to correct a broken tooth that had to be removed. You say that 
this was repair work to return your teeth to proper function. 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 
custom fabricated abutment (D6057) and abutment supported crown (D6059) provided on June 22, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy with 
biopsy (43239) performed on March 19, 2020. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy with biopsy. You indicate that 
this copayment is too expensive. 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 $325 
copayment for Medicare-covered surgery or other services provided at an ambulatory surgical center.  
 
You have been asked to pay a $325 copayment for an esophagogastroduodenoscopy with biopsy. An 
esophagogastroduodenoscopy with biopsy falls within the "Outpatient Surgery and Other Medical Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 esophagogastroduodenoscopy with biopsy (43239) performed on 
March 19, 2020.