Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvesacroiliac joint radiofrequency ablation for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is considered investigational and not medically necessary.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Ourphysician reviewer found RFA of the lateral sacral branches is considered experimental/ investigational because of the wide variation in efficacy in the literature. Therefore, the request is considered 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 Plandoes not haveto pre-approvesacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the semi-electric hospital bed. 
 
You asked the Plan to pay for the semi-electric hospital bed. You say that you are submitting this claim for 
appeal concerning the hospital bed. The Plan denied your request. The Plan says the documentation does not 
support the request for a semi-electric hospital bed as reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not clearly reveal that enrollee's condition has failed 
positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not 
feasible. The documentation does not support a need for an immediate or frequent changes in body position or 
special attachments that cannot be fixed on an ordinary bed and that the patient can operate the controls and 
cause the adjustments. The request for a semi-electric hospital bed is not medically necessary for this enrollee. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pay for the semi-electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and filling you received on January 15, 2020, and 
January 29, 2020. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says you are 
responsible for the payment. 
 
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 cost share responsibility. The Plan covers only those 
dental services listed in the Evidence of Coverage. Crowns are not covered. The Plan covers fillings with a 
70% coinsurance responsibility by the enrollee. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the crown 
and filling you received on January 15, 2020, and January 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible foran ultrasound (76770) provided on September 26, 2020.You asked the Plan to waive the deductible foran ultrasound. You say that you were told you would only have a $10 copayment.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 $300 deductible for in-network medicalservices including diagnostic procedures and tests. You have been asked to pay a $300 deductible for an ultrasound. An ultrasound falls within the in-network medical services including diagnostic procedures and tests 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 deductible foran ultrasound (76770) provided on September 26, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (CPT 
95940) provided to the enrollee on October 23, 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 place of service is inappropriate. 
 
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 95940 is "Continuous intraoperative neurophysiology 
monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes." 
 
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 CPT 95940 
would not be billable if services rendered in Place of Service 15 Mobile Unit. Per the American Academy of 
Neurology states "IONM services should be performed in Place of Service (POS) 19, 21, 22, or 24." Therefore 
this service would not be covered in Place of Service 15. 
 
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 continuous intraoperative neurophysiology monitoring (CPT 95940) provided to the enrollee on 
October 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
the lumbar spine without dye (72148) and MRI of neck spine without dye (72141) provided on July 22, 2020. 
 
You asked the Plan to waive the copayment for the MRI of the lumbar spine and MRI of neck spine. You say 
that you would like this copayment waived. The Plan denied your request. The Plan says the copayment has 
processed correctly at this time. 
 
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 $150 
copayment for diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay a $150 copayment for the MRI of the lumbar spine and MRI of neck spine. The 
services provided fall within the diagnostic and nuclear medicine radiological services benefit category. 
Although the Plan originally charged you two separate copayments for both MRIs, this was a mistake and they 
have waived the second copayment. 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 magnetic 
resonance imaging (MRI) of the lumbar spine without dye (72148) and MRI of neck spine without dye (72141) 
provided on July 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance angiography, neck (70547) magnetic 
resonance angiography, head (70544) provided August 11, 2020. 
 
You asked the Plan to pay for the diagnostic services. You say that claim denied for place of service. However, 
procedure was rendered in appropriate place of service. Please review and reconsider claim for payment. The 
Plan denied your request. The Plan says missing/incomplete/invalid/inappropriate place of service. 
 
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 find that CPT code  is not supported in the medical record. Specifically, the claim was billed 
with place of service 22 for outpatient. According to claims history the enrollee was inpatient during this date 
of service. Based on this information, we decided that Medicare rules for coverage of the diagnostic services 
have not been met. Therefore, we decided that the Plan does not have to pay for magnetic resonance 
angiography, neck (70547) magnetic resonance angiography, head (70544) provided August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visit provided by another 
provider on October 13, 2020. 
 
You asked the Plan to reduce the copayment for the urgent care visit provided by another provider. You say 
that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider 
your request. The Plan denied your request. The Plan says you received urgent care services provided by 
another provider on the date of service at issue in this appeal. The Plan says that the correct copayment has 
applied per your contract with the Plan. 
 
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 $45 
copayment for each covered office visit to other providers for urgently needed services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received urgent care 
services provided by another provider on October 13, 2020. You have been asked to pay a $45 copayment for 
the urgent care visit provided by another provider. The urgent care visit provided by another provider falls 
within the Urgently Needed 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 reduce the copayment for 
the urgent care visit provided by another provider on October 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for facet joint injections (64493). 
 
You asked the Plan to pay for the facet joint injections. You say that the injections are medically necessary. 
The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered when 
medically 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 pay for the facet joint injections. Our reviewer says 
that the injections are not medically necessary. Our physician reviewer found previous procedures only 
produced 50% pain relief. Coverage criteria has not been met. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pay for facet joint injections (64493).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approveroutine venipuncture from home.You asked the Plan to pre-approvethe routine venipuncture. You say that you have hip pain, back pain, and vertigo which makes it hard for you to get out of your home. You also say that you have multiple medical problems, and need to have this blood test done.The Plan denied your request. The Plan says blood draws are only medically necessary from home when there is another skilled service. The Plan also says that you are not getting any other skilled service.The Plan must follow Medicare rules. Medicare rules say that venipuncture for the purposes of obtaining a blood sample can no longer be the sole reason for Medicare home health eligibility.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the routine venipuncture have not been met.Therefore, we decided that the Plan does not have to pre-approveroutine venipuncture from home.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided by a 
participating provider on October 26, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you have never been charged 
for an ambulance trip before. 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 $300 
copayment for ambulance services.  
 
You have been asked to pay a $300 copayment for ambulance services. The correct copayment has been 
applied to the services that were provided. Ambulance services fall within the ambulance 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 ambulance services provided by a participating 
provider on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the remaining balance for the comprehensive oral evaluation 
(D0150), the periodontal scaling and root planing (D4341 x 2), the gingival irrigation (D4921 x 2), the 
localized delivery of microbial agents (D4381 x 5), and the full-mouth x-ray (D0210) provided from September 
10, 2020, to September 14, 2020. 
 
You asked the Plan to pay the remaining balance for the dental services. You say that you feel the financial 
representative and the dentist were very misleading and shared incorrect information. You say that you have 
paid almost $2,000 out-of-pocket for the services so far and cannot afford to pay anymore. The Plan denied 
your request. The Plan says gingival irrigation is not listed as a covered service. The Plan says the local 
delivery of microbial agents is not listed as a covered service either. The Plan says one comprehensive oral 
evaluation is covered every three calendar years. The Plan says one full-mouth x-ray or panoramic x-ray are 
covered once every five years. The Plan also says that the frequency limits for these services 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, the gingival irrigation and local 
delivery of microbial agents are not among those covered under this benefit. Additionally, the frequency limits 
for the comprehensive oral evaluation and full-mouth x-ray have been exceeded. The record shows that the 
Plan paid for a comprehensive oral evaluation and a panoramic x-ray that you received on September 4, 2020, 
thus exhausting the benefits for these services. Therefore, we decided that the Plan does not have to pay the 
remaining balance for the comprehensive oral evaluation (D0150), the periodontal scaling and root planing 
(D4341 x 2), the gingival irrigation (D4921 x 2), the localized delivery of microbial agents (D4381 x 5), and 
the full-mouth x-ray (D0210) provided from September 10, 2020, to September 14, 2020.  
 
Your complaint about being misled by the dentist and the dental office financial representative is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for the comprehensive oral evaluation (D0150), 
bitewing x-rays (D0274), a crown (D2740), the posterior filling (D2392), and the anterior filling (D2330) 
provided from February 8, 2020, to March 5, 2020. 
 
You asked the Plan to pay the full amount for the dental services. You say that the dental services are related to 
an injury in 2008. You say that the dentist keeps adding more work to be done. You say that you are very 
discouraged. You say that it is criminal that your previous employer denied you Worker?s Compensation. You 
say that your dental issues are causing other issues with your health. The Plan denied your request. The Plan 
says the provider in this case is out of network. The Plan says that dental service that you receive out of 
network are paid based on the in network fee schedule (INFS). The Plan also says that you are responsible for 
the different between the INFS and the dentist's charged fees. 
 
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, dental services that you receive out of 
network may be subject to a higher cost share. This is a contractual obligation you agreed to when you enrolled 
in the Plan?s dental coverage. Therefore, we decided that the Plan does not have to pay the full amount for the 
comprehensive oral evaluation (D0150), bitewing x-rays (D0274), a crown (D2740), the posterior filling 
(D2392), and the anterior filling (D2330) provided from February 8, 2020, to March 5, 2020.  
 
Your complaints about your dentist continuously adding more work to be done and your previous employer are 
not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate denture - maxillary (D5130), immediate 
denture - mandibular (D5140), and extraction, erupted tooth or exposed root (D7140) provided on September 
18, 2020. 
 
You asked the Plan to pay for the immediate denture - maxillary, immediate denture - mandibular, and 
extraction, erupted tooth or exposed root. You say that you had the supplemental benefit at the time. The Plan 
denied your request. The Plan says the services provided is not covered under your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
immediate denture - maxillary (D5130), immediate denture - mandibular (D5140), and extraction, erupted 
tooth or exposed root (D7140) provided on September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on October 5, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the provider only did 
an exam and x-ray, and you believe your insurance should cover it. The Plan denied your request. The Plan 
says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on July 22, 2020, and your problem focused limited oral evaluation 
(D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on October 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 22, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until September 24, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the services provided on September 22, 2019.