Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 1, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the physician service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained before the services were provided. 
The Plan also  says there are in network providers available for this service. 
 
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 July 1, 2020 by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper and lower dentures. 
 
You asked the Plan to pre-approve these services. You say that you need replacement dentures. The Plan 
denied your request. The Plan says the request exceeds the 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. The Plan covers one set of 
dentures every five years. 
 
We looked at the file and the Plan's rules. The file shows that you received a set of dentures on March 27, 2018 
for which the Plan approved and paid. You are not eligible for a new set of dentures until five years have 
passed from this date. Therefore, we decided that the Plan does not have to pre-approve complete upper and 
lower dentures.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Derma-gide for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical studies have not proven that this service is helpful for treatment of the 
health problem. 
 
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 pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is an experimental and investigational procedure. Therefore, the requested procedure is 
deemed not medically 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Derma-gide for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Hyaluronan injection provided on July 15, 2020.You asked the Plan to waive the coinsurance forthe Hyaluronan injection. You say that they injection was pre-approved and that you should only pay a $45 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 Part B drugs obtained in an in-network provider's office or outpatient setting for each Medicare-covered Part B drug. You have been asked to pay $413.52 which is 20% of the allowed amount for the Hyaluronan injection. The allowed amount is $2,067.60. ($2,067.60 x 20% = $413.52). The Hyaluronan injection falls within the "Medicare Part B prescription drugs" 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 forthe Hyaluronan injection provided on July 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a monitoring device coded as A9279 provided to the enrollee 
on July 1, 2020. 
 
You asked the Plan to pay for this item. You say that this claim should be paid. The Plan denied your request. 
The Plan says this device is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. Medicare does not cover precautionary equipment. The LCD specifically states this code is 
not covered. Therefore, we decided that the Plan does not have to pay for a monitoring device coded as A9279 
provided to the enrollee on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 12, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider is out-of-network with the member's Plan, the services were not 
approved in advance and the services were not urgent or emergent. 
 
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 12, 2020, 
by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99203) and an x-ray 
(73630) provided on September 8, 2020. 
 
You asked the Plan to waive the copayment for an office visit and an x-ray. You say that you should not be 
responsible for these charges because you are still in pain. The Plan denied your request. The Plan says this 
processed correctly. 
 
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 $55 
copayment for each Medicare-covered standard x-ray and a $50 copayment for each specialist office visit. 
 
You have been asked to pay a $50 copayment for an office visit and a $55 copayment for an x-ray. 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 office visit (99203) and an x-ray (73630) provided on September 
8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on August 31, 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 99232 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 99232 and 33285. Code 99232 is a column II code with a 
modifier indicator of 1 when billed with column I code 33285. Code 99232 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
subsequent hospital care rendered on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99204) provided on 
September 25, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you were told you would not be 
charged for this visit. The Plan denied your request. The Plan says this processed correctly. 
 
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 
copayment for an office visit with your PCP or a specialist.  
 
You have been asked to pay a $20 copayment for an office visit. 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 office visit (99204) provided on September 25, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to reduce the co payments for the urgent care visits provided. 
 
You asked the Plan to reduce the co payments for the urgent care visits. You say that you were seen at an urgent 
care center and not in an emergency room at a hospital. You say you should only have a $35 co payment. The 
Plan denied your request. The Plan says that you have been charged the correct cost sharing amount. 
 
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 $35 co payment for urgently needed services at an urgent 
care center.  
 
The Plan says you must pay a $90 co payment for each of the urgent care visits. Based on the Plan contract, 
however, you cannot be asked to pay more than a $35 co payment for each of the urgent care visits. The 
Explanations of Benefits show the servicing facility was an urgent care facility. Therefore, we decided that the 
Plan has to reduce the co payments for the urgent care visits provided. 
  
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that a more comprehensive genetic screening is 
needed to find any genetic abnormalities. The Plan denied your request. The Plan says testing is needed only 
once in a lifetime. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing is only covered under certain 
medical indications.  
 
We looked at the file and Medicare rules. The records show that you have previously received genetic testing. 
Coverage is indicated when you have not been previously tested with the same germline test using NGS for the 
same germline genetic content. 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 genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual physical exam provided on September 25, 2020. 
 
You asked the Plan to pay for this service. You say that this visit should be covered at no charge by the Plan. 
The Plan denied your request. The Plan says the annual physical was exhausted prior to this date of service on 
July 15, 2020. 
 
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 an annual physical is 
only covered once per year at no charge. Therefore, we decided that the Plan does not have to pay for an annual 
physical exam provided on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a night guard. 
 
You asked the Plan to pre-approve a night guard. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a night guard.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on 
September 24, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 24, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided  on September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the connective tissue grafts (D4273) provided on July 8, 
2020. 
 
You asked the Plan to pay for the connective tissue grafts (D4273). You say that the manual shows that the 
service is covered. You say that you have paid the claim in full and are submitting the claim for reimbursement. 
The Plan denied your request. The Plan says only one unit can be billed for each date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code D4273 is one. Three units of this code was billed, exceeding the MUE. 
Based on this information, we decided that Medicare rules for coverage of the connective tissue grafts (D4273) 
have not been met. Therefore, we decided that the Plan does not have to pay for the connective tissue grafts 
(D4273) provided on July 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $100 copayment charged for imaging services provided on 
September 2, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the services provided and the 
Plan contract agreement. 
 
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 $100 
copayment for outpatient imaging services. You have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the $100 copayment charged for imaging 
services provided on September 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (0275T).

You asked the Plan to pre-approve percutaneous image-guided lumbar decompression. You say that the enrollee will be enrolled in the CMS approved coverage with evidence development (CED) study  and Medicare advantage payers are responsible for payment of services for this type of clinical research study. The Plan denied your request. The Plan says the records provided do not support that the enrollee is actively enrolled in a CMS required clinical study.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous image-guided lumbar decompression have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (0275T).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer 
procedure. 
 
You asked the Plan to pre-approve the posterior interspinous decompression spacer procedure. You say that the 
requested treatment is considered safe and effective, as supported by its clinical benefits to patients continued 
medical professional adoption, and strong clinical evidence with numerous peer-reviewed studies. You say that 
the enrollee has failed more than 10 years of conservative approaches to treatment. The Plan denied your 
request. The Plan says medical studies haven't proven that the device is helpful for the treatment of the 
enrollee's health problem. 
 
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 pre-approve the posterior interspinous 
decompression spacer procedure. Our reviewer says that a posterior interspinous decompression spacer 
procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the 
enrollee has lumbar spinal stenosis. This device is considered experimental. More research is needed to show 
safety and efficacy. 
 
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 posterior interspinous decompression spacer procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a posterior interspinous decompression 
spacer procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D1999, D0140) provided on June 3, 
2020, and August 4, 2020. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services 
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 services are either not 
among those covered under this benefit, or are subject to a benefit limitation. The Plan contract covers only 
those dental services listed in the Evidence of Coverage. Dental code D1999 is not listed, and therefore is not 
covered. Additionally, code D0140 is covered once per year. The records show that this service was covered by 
the Plan for date of service June 3, 2020. The requested dental exam on August 4, 2020, exceeds the benefit 
limit and is not covered. Therefore, we decided that the Plan does not have to pay for the dental services 
(D1999, D0140) provided on June 3, 2020, and August 4, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the home health services provided from July 1, 
2020, to July 19, 2020. 
 
You asked the Plan to reimburse you for the home health services. You say that the home care services were 
necessary. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to ver ify the 
members coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
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 reimburse you for the home health services provided from July 1, 
2020, to July 19, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from March 
19, 2020, to April 17, 2020. 
 
You asked the Plan to pay for the SNF services. You say that the services in which the enrollee required and 
received during the dates of service in question are coverable under the Medicare Act. The Plan denied your 
request. The Plan says the services provided from March 19, 2020, to April 17, 2020, are considered custodial. 
The Plan says custodial services are services that can be provided safely and reasonably by someone without 
medical, nursing, or other professional training. The Plan also says that Medicare does not pay for these types 
of non-skilled services. 
 
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 the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing facility (SNF) services provided from March 19, 2020, to April 17, 2020.