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

 
We decided that the Plan does not have to pay for the assistant surgery services provided on April 9, 2020. 
 
You asked the Plan to pay for assistant services. You say that the surgical assistant was chosen by the operating 
surgeon. The Plan denied your request. The Plan says services of an assistant surgeon, co-surgeon, or surgical 
team are not covered for the procedure performed. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered.  
 
In this case, you billed assistant surgery services for CPT code 45020. The Medicare Fee Schedule Database 
contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant 
surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare 
coverage criteria have not been met. Therefore, we decided that the Plan does not have to pay for the assistant 
surgery services provided on April 9, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on July 26, 2019. 
 
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. 
 
The file shows that you received 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 July 26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facet injection, lumbar/sacral, single level (64493) and 
facet injection, lumbar/sacral, second level (64494). 
 
You asked the Plan to pre-approve a facet injection, lumbar/sacral, single level and facet injection, 
lumbar/sacral, second level. You say that the services are necessary. The Plan denied your request. The Plan 
says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when specific 
criteria is met.  
 
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 a facet injection, lumbar/sacral, single 
level and facet injection, lumbar/sacral, second level. Our reviewer says that the services are not medically 
necessary. Our physician reviewer found the enrollee has other pathology that is the probable pain generator 
here. Therefore, the request does not meet the coverage criteria and the request 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 a facet injection, lumbar/sacral, single level and facet injection, lumbar/sacral, 
second level have not been met. Therefore, we decided that the Plan does not have to pre-approve a facet 
injection, lumbar/sacral, single level (64493) and facet injection, lumbar/sacral, second level (64494).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services (A0427) received 
on January 28, 2020. 
 
The enrollee asked the Plan to waive the copayment for the ambulance services. The enrollee said that this 
copayment should be reconsidered. The Plan denied the enrollee's request. The Plan says the enrollee was 
charged this cost sharing 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). The enrollee's contract with the Plan clearly says that enrollees must 
pay a $285 copayment for each ambulance trip. The enrollee had 1 ambulance trip. The Plan charged the 
enrollee $285 for these services. This means that the enrollee has been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance services (A0427) received on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D testing provided on February 25, 2020. 
 
You asked the Plan to pay for the Vitamin D 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 a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The Vitamin D testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
Vitamin D testing provided on February 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you believe that IRF care is needed as you need 
more intensive therapy to help you regain function due to your Parkinson's. The Plan denied your request. The 
Plan says the criteria for IRF care are not met. 
 
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 enrollee is a male with a history of Parkinson's disease and deep vein blood clots. 
He was admitted to the hospital on 10/25/2020 with a hip fracture which required surgery. As of 10/29, he has 
toe-touch weight-bearing restrictions on the left leg and requires moderate assist to sit up, stand up, and sit 
down.  
 
The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not 
shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The 
enrollee is limited by his current weight-bearing status. The enrollee's care needs can be met at a lower level of 
care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EKG interpretation and report provided on May 10, 
2020. 
 
You asked the Plan to pay for the EKG interpretation and report (93010-59). You say that the Plan should pay 
this claim. The Plan denied your request. The Plan says there is no documentation or an interpretation note with 
a signature. Computer generated EKG reports don't meet the requirements for the professional component of an 
EKG. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
Per the Medicare Claims Processing Manual, Chapter 13, A/B MACs (B) generally distinguish between an 
interpretation and report of an x-ray or an EKG procedure and a review of the procedure. A professional 
component billing based on a review of the findings of these procedures, without a complete, written report 
similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate 
payment of the service. This is because the review is already included in the emergency department evaluation 
and management (E/M) payment. The documentation reviewed shows an interpretation and EKG strip 
completed, but it is not a complete written report.  Based on this information, we decided that Medicare rules 
for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does 
not have to pay for the EKG interpretation and report provided on May 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit you had on July 14, 
2020. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that this visit was done as a pre-op 
visit for surgery.  You said that your surgery was canceled due to COVID-19, so you had to repeat the pre-op 
visit.  You stated that you should have this copayment waived because you had to do everything twice. The 
Plan denied your request. The Plan says that you were charged this copayment 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 $35 
copayment for specialist visits.  
 
You have been asked to pay a $35 copayment for the specialist visit. This copayment applies regardless of the 
reason for the 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 the specialist visit you had on 
July 14, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department and rabies 
vaccine services provided May 29, 2020. 
 
You asked the Plan to waive the copayment for the emergency services. You say that you are appealing these 
charges because this is a forced provider because the only place to receive this treatment is the ER and the 
charges should not apply. The Plan denied your request. The Plan says this claim processed correctly with the 
correct copayment applied per the plan benefits. 
 
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 $120 
copay for each Medicare covered emergency room visit for Emergency care.  
 
You have been asked to pay $120 copay for each Medicare covered emergency room visit for the emergency 
services. the emergency services fall within the Emergency 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 emergency department and rabies vaccine services provided May 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided by a participating 
provider on June 19, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that this is $100 more than you paid last year. 
You say that this is too high during a pandemic. The Plan denied your request. The Plan says the correct 
copayment has been 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 outpatient diagnostic tests/diagnostic radiology services.  
 
You have been asked to pay a $325 copayment for an MRI. The correct copayment has been applied to the 
services that were provided. An MRI falls within the outpatient diagnostic tests/diagnostic radiology services 
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 MRI provided by a 
participating provider on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two custom fabricated abutments (D6057 x2) and two 
implant supported crowns (D6066 x2). 
 
You asked the Plan to pre-approve the custom fabricated abutments and implant supported crowns. You say 
that the enrollee needs these services in order to complete the implant procedure that they received last year.  
The Plan denied your request. The Plan says these services are not covered under your benefit package. 
 
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 pre-approve two 
custom fabricated abutments (D6057 x2) and two implant supported crowns (D6066 x2).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on May 6, 2020. 
 
You asked the Plan to pay for electrocardiogram. You say that this service was performed three times. The Plan 
denied your request. The Plan says the documentation shows this was performed by two providers. 
 
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 93010-77 is not supported in the medical record. Specifically, the submitted medical 
records do not include documentation of this service being performed by the billed servicing provider. Based 
on this information, we decided that Medicare rules for coverage of electrocardiogram have not been met. 
Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010) provided on May 6, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services provided at an outpatient 
hospital facility, on July 1, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that you have these labs every year 
and they have been covered. The Plan denied your request. The Plan says you were charged this copayment 
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 $40 
copayment for lab services in an outpatient hospital facility.  
 
You have been asked to pay a $40 copayment for the lab services. 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 lab services provided at an outpatient hospital facility, on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis provided by a participating 
provider on February 6, 2020, to March 31, 2020. 
 
You asked the Plan to waive the coinsurance for dialysis. You say that you think your coverage was changed 
without your approval. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for services to treat kidney disease.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for dialysis. The total allowed amount is 
$7,056. The total amount you are being asked to pay is $1,411.20 ($7,056 x 20% = $1,411.20). Dialysis falls 
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 dialysis provided by a participating provider on February 6, 2020, to March 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis provided on February 20, 2020. 
 
You asked the Plan to pay for the prophylaxis. You say that your dentist recommended you receive 3 cleanings 
per year, due to your diagnosis of being at risk for gum disease. You also say that you are on a fixed income, 
and paying additional costs is a burden to you. The Plan denied your request. The Plan says your benefit limit 
had been exceeded for this service. 
 
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, cleanings are limited to once every 6 
months. The record shows that you received a dental cleaning on November 22, 2019, and your cleanings 
benefit had been exhausted for the 6 month time period. Therefore, we decided that the Plan does not have to 
pay for the prophylaxis provided on February 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diagnostic radiology services provided on July 1, 2020. 
 
You asked the Plan to waive the deductible for an x-ray. You say that this was not done correctly so you don't 
think you should have to pay for this. The Plan denied your request. The Plan says the correct deductible 
amount has been applied. 
 
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 there is a $250 deductible for outpatient diagnostic tests/diagnostic radiology 
services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests/diagnostic radiology services. Since an x-ray was provided, the correct copayment has been 
applied. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 
deductible for outpatient diagnostic tests/diagnostic radiology services. This cost sharing is a contractual 
obligation that had not been met at the time an x-ray was received on July 1, 2020. The total amount you are 
being asked to pay $137.94. Therefore, we decided that the Plan does not have to waive the deductible for 
diagnostic radiology services provided on July 1, 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 June 7 to 
June 9, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the inpatient hospital 
stay was caused by your neurologist's negligence. 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 $95 
copayment for each day for days 1-5 per admission.  
 
You have been asked to pay $190, or a $95 copayment for 2 days of 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 June 7 to June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular 
denture provided on June 4, 2020. 
 
You asked the Plan to pay for the complete maxillary and mandibular dentures. You say that your current plan 
benefit summary did not say that you had a frequency limitation within the company as it does imply only 
within the Plan. The Plan denied your request. The Plan says the benefits for these services have been satisfied 
and the frequency limitations have been exceeded. 
 
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, complete dentures are limited to one 
upper complete and/or one lower complete denture every five years. The record shows that you received a 
complete maxillary denture and complete mandibular denture on March 21, 2016, and your complete upper and 
lower denture benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the 
complete maxillary denture and complete mandibular denture provided on June 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three gingival irrigations (D4921 x3) provided on June 3, 
2020. 
 
You asked the Plan to pay for the gingival irrigations. You say that this service was medically necessary, and 
an anti-bacterial treatment for acute periodontal disease flare-ups. The Plan denied your request. The Plan says 
this service is not a covered benefit 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 three 
gingival irrigations (D4921 x3) provided on June 3, 2020.