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

 
We decided that the Plan does not have to pay more for the initial periapical x-ray (D0220), the additional 
periapical x-ray (D0230), the palliative treatment of dental pain (D9110), and the extraction (D7140) provided 
from June 22, 2020, to July 2, 2020. 
 
You asked the Plan to pay more for the dental services. You say that the copayment for extractions is 50%. 
You say that the plan only made a payment of $37.50. You say that the services you received on June 22, 2020 
were not paid correctly either. You also say that the services should be paid at 50% per your Evidence of 
Coverage. The Plan denied your request. The Plan says the claim processed correctly. The Plan says you may 
be billed by the out of network provider for any amount greater than the payment made by the plan to the 
provider. 
 
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, you may be billed by the out of 
network provider for any amount greater than the payment made by the plan to the provider.  
 
 
 
 
 
 
 
 
CPT Code Billed Allowed Plan Paid Cost Share Billed -Allowed Your Responsibility 
D9110 $61 $48 $24 $24 $13 $37 
D0220 $34 $15 $15 $0 $22 $22 
D0230 $27 $11 $11 $0 $16 $16 
D7140 $237 $75 $37.50 $35.50 $162 $199.50 
TOTAL:      $274.50 
 
 
Additionally, cost sharing is a contractual obligation under the plan and cannot be waived. Therefore, we 
decided that the Plan does not have to pay more for the initial periapical x-ray (D0220), the additional 
periapical x-ray (D0230), the palliative treatment of dental pain (D9110), and the extraction (D7140) provided 
from June 22, 2020, to July 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because the enrollee did not have 
advanced lung cancer at the time this testing was performed, and it is therefore not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered by Medicare 
when the enrollee has been diagnosed with advanced NSCLC and certain conditions have been met.  
 
We looked at the file and Medicare rules. This testing was ordered for a diagnosis other than advanced 
NSCLC. The Plan issued prior notice that this testing would not be covered. Based on this information, we 
decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for Guardant360 testing provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for cataract removal and does not have to waive 
the copayment for a specialist visit provided from January 29, 2020, to February 11, 2020. 
 
You asked the Plan to waive the deductible for cataract removal and to waive the copayment for a specialist 
visit. You say that you were not aware that an out-of-network provider would be assisting during the surgery. 
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. Your 
contract with the Plan says that there is a $1,000 deductible. Your contract with the Plan also clearly says that 
you must pay a $25 copayment for specialist visits.  
 
You received cataract removal on January 29, 2020. The record shows that you had paid $0 toward the $1,000 
deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of 
$519.35.  
 
You received a specialist visit on February 11, 2020. Therefore, you are responsible to pay the $25 copayment.  
 
The total amount you owe is: $544.35. 

The items or services you asked the Plan to waive the deductible and copayment for fall within the benefit 
categories: outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers and physician/practitioner services, including doctor's office visits. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has also 
followed Medicare rules by clearly disclosing in the contract that there is a $25 copayment for specialist visits. 
This cost sharing is a contractual obligation that had not been met at the time cataract removal and a specialist 
visit were received on January 29, 2020 to February 11, 2020. Therefore, we decided that the Plan does not 
have to waive the deductible for cataract removal and does not have to waive the copayment for a specialist 
visit provided from January 29, 2020, to February 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Superion 
Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that this is the most appropriate treatment for the 
enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the role of this technology remains uncertain and it is not covered by the Plan. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is still considered an experimental/investigational procedure and it has not been 
incorporated into clinical practice guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interspinous spacer device (Superion Vertiflex).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on July 13, 
2020. 
 
You asked the Plan to pay for the dental service. You say that your tooth broke off. You say that the root was 
jagged in your mouth. You also say that it needed to be repaired so you could eat properly. The Plan denied 
your request. The Plan says limited oral evaluation is covered once per plan year. The Plan says the frequency 
limit has 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 and the service is listed as covered, the 
frequency limit of 1 per plan year has been exceeded. The record shows that you received this service on 
January 6, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation 
(D0140) provided on July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's care is 
not complex, and she does not need a team of providers. 
 
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 physician reviewer found 
that the enrollee is status post left hip fracture. She is medically stable. There is no evidence of medical issues 
that require monitoring by an inpatient rehab physician three times a week. The documentation does not 
support that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary 
approach to rehab care. The enrollee will benefit from physical and occupational therapy, but does not need the 
services in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup and endodontic therapy. 
 
You asked the Plan to pre-approve the core buildup and endodontic therapy services. You say that the records 
provided support the need for the services being requested. The Plan denied your request. The Plan says the 
services which remain in dispute are not covered benefits under Medicare or your contract. 
 
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 core 
buildup and endodontic therapy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transforaminal epidural injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says there must be at least two weeks of pain reduction of greater or equal to 50%, functional 
improvement, and decrease in medication. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation prior epidural steroid injections in the enrollee. What is clearly documented is 
multi-level forminal stenosis and spinal stenosis. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transforaminal epidural injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2752) provided on June 23, 2020. 
 
You asked the Plan to pay for the dental service. You say that your tooth was broken and causing you pain. 
You say that you did not know you had dental insurance that you could use for this service. You say that you 
thought you had a stipend. You say that this was not an elective procedure. You also say that you do not have 
money laying around to pay for this. The Plan denied your request. The Plan says the crown is not listed as a 
covered 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, the requested items or services are not 
among those covered under this benefit. Additionally, the Evidence of Coverage clearly states that any service 
not listed is not covered. Therefore, we decided that the Plan does not have to pay for the crown (D2752) 
provided on June 23, 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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you required supervision and stand-by assistance for grooming. You required moderate assistance with lower body dressing. You required minimal to moderate assistance for mobility. The documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care. Your 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided May 27, 2020.

You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says the CPT code shares a Column I / Column II relationship with another code billed.

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, we have confirmed that code the x-ray has a Column I / Column II relationship with code 32555 and cannot be paid as billed. An appropriate modifier was not included. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT Code 64493).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary. 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 services. Our physician reviewer found the LCD requires that facet blocks be performed only if no other pain generators explain your low back pain. Here there are several other probable pain generators. Therefore, 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (CPT Code 64493).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injection (27096). 
 
You asked the Plan to pre-approve sacroiliac joint injection. You say that the sacroiliac injections are medically 
necessary to relieve the pain and to improve the daily function as the enrollee is suffering from continuous 
sacroilitis and bilateral episacral pain. The Plan denied your request. The Plan says the records do not support 
medical necessity of the request service. 
 
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 sacroiliac joint injection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not document the enrollee's test, thigh thrust, SI compression 
test, Yeoman's test or Gaenslan's test. The appeal note from the prescriber dated 9/22/2020 states that the 
enrollee has positive Patrick's test, SI compression test and SI joint tenderness. The note also states that the 
enrollee has positive straight leg raising test on the left. The provided medical records do not document that the 
enrollee has satisfied the above requirements for medical necessity. Therefore, this procedure is not medically 
necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sacroiliac joint injection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac joint injection (27096).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on June 15, 2020. 
 
You asked the Plan to waive the coinsurance for a brace. You say that you cannot afford this. 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 other benefits/durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a brace. The total allowed amount is 
$471.57. The total amount you are being asked to pay is $94.31 ($471.57 x 20% = $94.31). A brace falls within 
the other benefits/durable medical equipment 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 durable medical equipment provided by a participating provider on June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D testing provided on March 30, 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 provided 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 March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with this 
copayment. 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 $40 
copayment for physician/practitioner services/II/specialist visit/in-network.  
 
You have been asked to pay a $40 copayment for a specialist office visit. A specialist office visit falls within 
the physician/practitioner services/II/specialist visit/in-network 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 specialist office visit provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator leads, alcohol wipes and 
lumbar sacral orthosis provided on March 26, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator device leads (A4595), alcohol wipes (A4245) and 
lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim. The Plan denied your request. The 
Plan says the enrollee has a lumbar-sacral orthosis still under reasonable useful lifetime and there is no proof of 
delivery for the leads and wipes. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee had a lumbar-sacral orthosis (L0650) received on 6/26/17. The lumbar-sacral 
orthosis (L0650) serves the same purpose as the lumbar-sacral orthosis (L0650) at issue. This orthosis is still 
within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, 
irreparably damaged, or that the enrollee had a change in medical condition to warrant the lumbar-sacral 
orthosis at issue. The record does not contain a valid proof of delivery for the supplies provided in this case. 
there is no itemized shipping/billing invoice to indicate the specific supplies, or Proof of Delivery indicating 
the billed items were delivered. 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 
neuromuscular stimulator leads, alcohol wipes and lumbar sacral orthosis provided on March 26, 2020.