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

 
We decided that the Plan does not have to pay for the panoramic x-ray, extraction, and palliative (emergency) 
treatment of dental pain provided on March 24, 2020. 
 
You asked the Plan to pay for the panoramic x-ray, extraction, and emergency treatment of dental pain. You 
say that you checked the Plan's website and saw that extractions were listed as a covered service. The Plan 
denied your request. The Plan says you have already received your maximum benefit of $100 for non-Medicare 
covered dental services. The Plan also says that you are responsible for the full cost of the disputed non-
Medicare covered 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, the Plan offers a $100 annual dental 
benefit allowance. The contract says that you are responsible for any amount above the dental coverage limit. 
The record shows that you met the annual maximum benefit on January 16, 2020 and your annual maximum 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray, 
extraction, and palliative (emergency) treatment of dental pain provided on March 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you do not understand why the ambulance 
services are not covered by the Plan. You say that sometimes you get very weak and dizzy which can cause you 
to fall. You stated that when this happens, you need help standing up again. You asked the Plan to reconsider 
providing coverage. 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 May 15, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, maxillary partial denture, and mandibular 
partial denture provided on January 23, 2020 by an OON provider. 
 
You asked the Plan to pay for the extraction, maxillary partial denture, and mandibular partial denture. You say 
that in 2016 you notified the Plan that there were no in-network dental providers in your area, and the ones in-
network said they did not accept your insurance plan. You say that in January of 2020, you contacted the same 
in-network providers, and were again told that they do not accept your insurance plan. The Plan denied your 
request. The Plan says these services were rendered by an OON provider. The Plan also says that this Plan does 
not include OON 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 
covered when they are received OON. The records show that there are in-network dental providers in your 
service area that can provide the dental services that are covered under the Plan. Therefore, we decided that the 
Plan does not have to pay for the extraction, maxillary partial denture, and mandibular partial denture provided 
on January 23, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 21, 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) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures (97112), electrical stimulation 
(97032), vasopneumatic devices (97016) and injections (96372, ZJ3490, J3420, J3415 and J3411) provided on 
December 4, 2019. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says coverage of chiropractic service is 
specifically limited to treatment by means of manual manipulation, 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for therapeutic procedures (97112), electrical stimulation (97032), vasopneumatic 
devices (97016) and injections (96372, ZJ3490, J3420, J3415 and J3411) provided on December 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
March 13, 2020 to March 20, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be 
responsible for the 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 a $225 
copayment per day, for days 1-7 for Medicare-covered in-network hospital stays.  
 
You have been asked to pay a $225 copayment for each day of the inpatient hospital stay. ($225 x 7 = $1,575). 
The 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 the inpatient hospital stay provided from March 13, 2020 to March 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies for external drug infusion pump 
(A4222) provided November 25, 2019 to December 1, 2019. 
 
You asked the Plan to pay for the infusion supplies. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says the billed services were not 
supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery and itemized shipping/billing invoice for the supplies 
provided in this case. More specifically, the submitted itemized shipping/billing invoice and proof of delivery 
do not indicate that the infusion supplies with billed units were delivered to the enrollee for the billed date 
range. The record shows that the Plan made several attempts to obtain the necessary documentation without 
success. Therefore, we decided that the Plan does not have to pay for the infusion supplies for external drug 
infusion pump (A4222) provided November 25, 2019 to December 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a routine eye exam provided on November 
4, 2019. 
 
You asked the Plan to waive the copayment for the routine eye exam. You say that you would like 
reconsideration because you paid a $25 copayment at the office and are now being billed $40. The Plan denied 
your request. The Plan says the contract says that you owe a $40 copayment per visit for Medicare-covered 
exams to diagnose and treat diseases of the eye, including an annual glaucoma screening for members at high 
risk. 
 
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 $40 
copayment for Vision Care.  
 
You have been asked to pay a $40 copayment for the routine eye exam. The routine eye exam falls within the 
Vision 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 a routine eye exam 
provided on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first 15 minutes of IV moderate (conscious) 
sedation/analgesia (D9239) and each 15 minute increment of IV moderate (conscious) sedation/analgesia 
(D9243) provided on March 26, 2020. 
 
You asked the Plan to pay for the IV moderate (conscious) sedation/analgesia services. You say that the 
treating provider informed you that Novocaine would not have been enough coverage for your tooth to be 
extracted. The Plan denied your request. The Plan says these services are not included in the benefits section of 
your Evidence of Coverage. 
 
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 first 
15 minutes of IV moderate (conscious) sedation/analgesia (D9239) and each 15 minute increment of IV 
moderate (conscious) sedation/analgesia (D9243) provided on March 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urology services (CPT 50820) provided to the enrollee on 
December 19, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code requires an anatomical modifier. 
 
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 50820 is "Ureteroileal conduit (ileal bladder), including 
intestine anastomosis (Bricker operation)." 
 
We find that CPT code 50820 is not supported in the medical record. Specifically, this code requires an 
anatomical modifier, which cannot be found in the case file. 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 urology services (CPT 50820) provided to the enrollee on December 19, 2019.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for medical services provided on February 25, 2020. 
 
You asked the Plan to pay for the medical services. You say that the enrollee's health issues warranted the 
services provided, which were medically necessary. The Plan denied your request. The Plan says that the 
provider is not certified for Medicare. 
 
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. Specifically, the Plan did not provide information to support that this provider is 
not enrolled in Medicare. We found that the provider who supplied the services in dispute is enrolled and 
actively certified as a Medicare provider. The Plan has not substantiated their denial reason. Therefore, we 
decided that the Plan has to pay for medical services provided on February 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from December 17, 2019 to 
March 2, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says our plan 
must give approval in advance before services can be provided with other providers in the plans network. 
 
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 did not pre-approve 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 physician's services provided from December 17, 2019 to March 
2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of an interim implant body for 
transitional prosthesis: endosteal implant, semi-precision attachment abutment, and abutment supported 
porcelain fused to metal crown provided on April 10, 2019 and February 5, 2020. 
 
You asked the Plan to pay for the endosteal implant, semi-precision attachment abutment, and abutment 
supported porcelain fused to metal crown. You say that these services should be covered because they are 
related to dental implant work that is related to the extraction of tooth #19, which was broken due to an injury. 
You also say that the documentation says treatment of teeth due to an injury is covered under your medical 
plan. The Plan denied your request. The Plan says the treating provider opted out of Medicare, effective 
February 16, 2016 to February 16, 2022. The Plan also says that the Health Plan will not reimburse for charges 
incurred by Medicare opt out providers. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the surgical placement of an interim implant body for transitional prosthesis: endosteal implant, semi-precision 
attachment abutment, and abutment supported porcelain fused to metal crown provided on April 10, 2019 and 
February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 10, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 did not pre-approve the physician's services. 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 physician's services provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion pump refill kit provided on January 23, 2020. 
 
You asked the Plan to pay for the refill kit. You say that it is necessary that the programming of the pump and 
its refill be a medical professional. The Plan denied your request. The Plan says the cost of this service is 
included in payment for the device and medication. 
 
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 A4220 is refill kit for implantable infusion pump. We 
looked at the file and the rules. We find that CPT code A4220 is bundled into payment for other services. This 
code cannot be paid as a separate line item. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the infusion pump 
refill kit provided on January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on 
May 21, 2020. 
 
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you have been seeing 
the same dentist for decades. You say that you were not informed of the preferred provider requirement. The 
Plan denied your request. The Plan says out-of-network dental 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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis and periodic oral evaluation provided on May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation and prophylaxis provided 
on December 17, 2019 by an OON provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation and prophylaxis. You say that your wife 
received reimbursement for dental services, but yours were refused. The Plan denied your request. The Plan 
says these services were rendered by a non-contracted provider. The Plan also says that no benefits are 
available for procedures performed by OON providers. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation and prophylaxis provided on December 17, 2019 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing panel provided on September 10, 
2019. 
 
You asked the Plan to pay for the definitive drug testing panel. You say that this testing was medically 
necessary and should be paid. The Plan denied your request. The Plan says the order provided is unsigned. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by a treating 
provider. Although an order need not be signed, the records must confirm the intent that the testing be 
performed. 
 
In this case, the file contains an unsigned order for the provider's custom panel. No records were submitted to 
corroborate that this testing was intended to be performed by the physician. Therefore, we decided that the Plan 
does not have to pay for the definitive drug testing panel provided on September 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fasciotomy services (CPT 26045) provided to the enrollee on 
January 23, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says CPT 26045-LT is not supported by the medical records submitted. 
 
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 26045 is "open partial palmar (Dupuytren's contracture) 
fasciotomy." 
 
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 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
operative report documents that a Palmar and a Digit of F3 and F4 fasciotomy was performed. During the 
procedure, surgeon documents, "An intrinsic release involving the small and ring fingers involve the 
interosseous musulature and the lumbricals. The tissue was excised." The operative report does not support 
CPT 26045. 
 
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 fasciotomy services (CPT 26045) provided to the enrollee on January 23, 2020.