Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on August 12, 
2019. 
 
You asked the Plan to pay for the services. You say that this should be paid or. The Plan denied your request. 
The Plan says the final claim was not received in the required time. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
A valid 60-day episode of care claim was not received 60 days after the paid date of the RAP claim. 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 home health services provided to the enrollee on August 12, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the full amount up to the annual maximum allowance for 
removal of benign odontogenic cyst or tumor (D7241 x 4) provided on June 29, 2020. 
 
You asked the Plan to reimburse the full amount up to the annual maximum allowance for the dental services. 
You say that there is a $1,000 annual maximum allowance. You say that you have only received $890 of the 
$1,000 benefit. You say that nowhere in the 2020 Benefit Guide does it mention that 50% is the limit, only the 
maximum allowance of $1,000. You also say that you believe you are due an additional $110. The Plan denied 
your request. The Plan says there is a 50% coinsurance for comprehensive dental services. 
 
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 50% coinsurance for 
comprehensive dental services. The Evidence of Coverage clearly states that you are responsible for 50% of the 
cost for comprehensive dental services. Therefore, we decided that the Plan does not have to reimburse the full 
amount up to the annual maximum allowance for removal of benign odontogenic cyst or tumor (D7241 x 4) 
provided on June 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on May 21, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier has not been appended to show 
the procedure was separate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 71045 is radiologic examination, chest; single view. We 
find that CPT code 71045 is not supported. Specifically, the medical records provided do not show that the 
service was billed with ta valid modifier to show the service was a distinct procedural service. Based on this 
information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we 
decided that the Plan does not have to pay for the chest x-ray provided on May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7140 and D7210) provided on July 9, 
2020. 
 
You asked the Plan to pay for the extractions (D7140 and D7210). You say that the extractions were not done 
for cosmetic reasons. You say that your options were to live without a bridge or get dentures. 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 
extractions (D7140 and D7210) provided on July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on 
June 16, 2020. 
 
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the 
charges because you did not receive any follow-up from the provider. 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 DME and related supplies.  
 
You received DME and related supplies on June 16, 2020. The total allowed amount is $105.76 and 20% of 
that is $21.15. 
 
You have been asked to pay the total coinsurance amount of $21.15 for DME and related supplies. DME and 
related supplies fall within the 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 DME and related supplies provided on June 16, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on February 19, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the services are 
not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the lab services by a contract provider. The file does not show that the Plan provided 
notice that the lab services would not be covered. Under Medicare rules, this means the lab services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided 
on February 19, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an ER visit provided from May 18, 2020, to May 19, 
2020. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you were admitted to the hospital and 
should not owe a copayment. The Plan denied your request. The Plan says that the claims were processed 
correctly and you are being charged the correct 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 provide medical records. Without medical records we cannot 
determine whether you were admitted inpatient or not. Therefore, we decided that the Plan has to waive the 
copayment for an ER visit provided from May 18, 2020, to May 19, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular junction (NMJ) testing provided on June 
8, 2020. 
 
You asked the Plan to pay for the NMJ testing. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that NMJ testing is covered for the above 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 the NMJ testing. Our reviewer says that the 
requested NMJ testing is not medically reasonable and necessary. Our physician reviewer found that the 
documentation does not support that the enrollee has myasthenia gravis, Lambert Eaton myasthenic syndrome 
(LEMS), botulinum toxicity, exposure to certain drugs such as aminoglycoside antibiotics or D-Penicillamine, 
or that he has required paralyzation for mechanical ventilation. 
 
 
 
 
 
 
 
 
 
 
 
 
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 NMJ testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the neuromuscular junction (NMJ) testing provided on June 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded 
14041 provided on February 27, 2020. 
 
You asked the Plan to pay for the adjacent tissue transfer or rearrangement services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 14041 is adjacent tissue transfer or rearrangement, 
forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm. 
 
We find that CPT code 14041 is not supported in the medical record. Specifically, the operative report did not 
include documentation of an adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, 
axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm; therefor, this code cannot be verified. 
Based on this information, we decided that Medicare rules for coverage of the adjacent tissue transfer or 
rearrangement services have not been met. Therefore, we decided that the Plan does not have to pay for the 
adjacent tissue transfer or rearrangement services coded 14041 provided on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics received on June 17, 2020. 
 
You asked the Plan to pay for the foot orthotics. You say that you would like the plan to reconsider their denial 
The Plan denied your request. The Plan says the items received are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics received on June 17, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided on June 15, 2020. 
 
You asked the Plan to pay for the pulp vitality tests (D0460). You say that the provider needed the testing to 
determine the health of the teeth in the upper left quadrant. The Plan denied your request. The Plan says the 
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 pulp 
vitality tests (D0460) provided on June 15, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided to you on July 22, 2019. 
 
You asked the Plan to pay for the lab services. You say that this should be covered. The Plan denied your 
request. The Plan says that these services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services are considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided to you on 
July 22, 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 the MRI scan coded 70553 provided on January 10, 2020. 
 
You asked the Plan to pay for the MRI scan. 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. 
 
We find that CPT code 70553 is not supported in the medical record. Specifically, this claim was billed with 
place of service 22 (outpatient). However, the documentation supports that the enrollee was inpatient during 
this date of service. Based on this information, we decided that Medicare rules for coverage of the MRI scan 
have not been met. Therefore, we decided that the Plan does not have to pay for the MRI scan coded 70553 
provided on January 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from March 6, 
2020, to March 12, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that your copayment should 
be waived due to COVID-19 testing. 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 a $285 
copayment for days 1-6 for inpatient hospital care.  
 
You had an inpatient hospital stay from March 6, 2020, to March 12, 2020. Therefore, you are responsible to 
pay a $285 copayment for days 1-6 (March 6, 2020, to March 11, 2020). $285 (copayment) x 6 (inpatient days) 
= $1,710.  
 
You have been asked to pay the total copayment amount of $1,710 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay from March 6, 2020, to March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on May 17, 2020, to June 
17, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that prescribed medication for the pain did not 
work. The Plan denied your request. The Plan says prior 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 you must get a referral from your PCP prior to getting care from out-of-network providers via 
your Point of Service benefit. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. The documentation did not include a referral from your PCP for the services at issue. We found no 
exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not 
have to pay for the chiropractic services provided on May 17, 2020, to June 17, 2020, by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-care/home management training and therapeutic 
procedure services provided on July 6, 2020 and July 14, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the self-care/home management training and therapeutic procedure services. You 
say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the 
services rendered are not a covered benefit. 
 
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 self-care/home management training and 
therapeutic procedure services provided on July 6, 2020 and July 14, 2020 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 bitewings (D0274) provided on July 10, 2020. 
 
You asked the Plan to pay for the bitewings. You say that you were told that this procedure was coded 
incorrectly, and also believe it would be unethical to change the code. The Plan denied your request. The Plan 
says this service is not covered by your health plan or Medicare. 
 
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, 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 
bitewings (D0274) provided on July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided on April 3, 
2020. 
 
You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted 
did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The 
documentation does not include the time spent providing this service. Based on this information, we decided 
that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the 
Plan does not have to pay for the critical care services coded 99291 provided on April 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator provided on March 20, 2020. 
 
You asked the Plan to pay for neuromuscular stimulator. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of payment for this item is correct, because this item was ordered 
by telemedicine which is not covered for the enrollee's geographic area. 
 
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 neuromuscular stimulator 
provided on March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genicular nerve injection provided on March 24, 2020. 
 
You asked the Plan to pay for the provided services. You say that the enrollee attempted conservative treatment 
for an appropriate amount of time. The Plan denied your request. The Plan says the effectiveness 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 provided services. Our physician 
reviewer found that the enrollee has chronic radiating bilateral knee pain.  The enrollee has had bilateral total 
knee prostheses. The effectiveness of genicular nerve blocks to treat knee pain has not been established.   
Genicular nerve blocks are considered experimental/investigational in nature. As such, the right genicular nerve 
block to treat chronic knee pain was not medically reasonable and necessary to treat the enrollee. 
 
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 provided services have not been met. Therefore, we decided that the Plan 
does not have to pay for the genicular nerve injection provided on March 24, 2020.