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

 
We decided that the Plan does not have to pay for chiropractic services (CPT 97014, CPT 97010, CPT 99201) 
received on May 15, 2020 and May 20, 2020. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for chiropractic services (CPT 97014, CPT 97010, CPT 99201) received on 
May 15, 2020 and May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 22, 2020 by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that it was your understanding that an exception 
was made to allow for the out-of-network charge. The Plan denied your request. The Plan says there is no 
authorization/referral on file for the date of service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on January 22, 2020 
by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of the seminal vesicles (coded as 55650) 
provided during a laparoscopic radical prostatectomy (coded 55866) on the date of service, January 14, 2020. 
 
You asked the Plan to pay for the separately reported seminal vesicle removal. You say that the code 55650 is 
not bundled with any other procedure performed on this date and should be separately paid. The Plan denied 
your request. The Plan says this service is integral to the radical prostatectomy meaning it should not be 
separately reported. 
 
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure 
are considered bundled into that procedure and, therefore, are considered a component part of the 
comprehensive code. 
 
In this case, the AMA CPT Assistant Archives include an article regarding code 55866. This article includes a 
detailed description of the procedure for which this code is reported. The description states "The laparoscope is 
introduced and attention is turned to first dissecting the seminal vesicles and vas deferens...The seminal 
vesicles are carefully dissected out using the harmonic scalpel to divide all bleeding vessels until the structures 
are freed completely." 
 
This description supports that vesiculectomy is an integral part of the surgical procedure described and 
reimbursed through code 55866. As such, it is not appropriate to separately report this service. Therefore, we 
decided that the Plan does not have to pay for the removal of the seminal vesicles (coded as 55650) provided 
during a laparoscopic radical prostatectomy (coded 55866) on the date of service, January 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0433 and A0425) provided on January 
10, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the 
member should not have been transported from the hospital. The Plan denied your request. The Plan says this 
service was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that providers must report revenue code 540. 
 
We find that CPT code A0433 and A0425 is not supported in the record. Specifically, this claim was reported 
with an inappropriate revenue code. Based on this information, we decided that Medicare rules for coverage of 
the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance services (A0433 and A0425) provided on January 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transport provided on December 31, 2019. 
 
You asked the Plan to pay for the air ambulance transport. You say that this was an emergent scene air 
transport for the member. The Plan denied your request. The Plan says there are several local hospitals within a 
short driving distance where the member could have been taken to. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the air ambulance transport have not been met. There are several local  hospitals within a short 
driving distance where the member could have been taken to. Therefore, we decided that the Plan does not 
have to pay for the air ambulance transport provided on December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that you require the device after 
surgery to prevent blood clots. The Plan denied your request. The Plan says pneumatic compression devices are 
not covered by Medicare for preventative services like preventing deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. The submitted documentation reflects that the enrollee was prescribed an intermittent limb 
compression device for the prevention of deep vein thrombosis (DVT) following knee surgery. As such, this 
was applied as a preventative service, which is not covered. Based on this information, we decided that 
Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided 
that the Plan does not have to pay for intermittent limb compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services rendered on February 25, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 64488-59 is not supported. 
 
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.   
 
We asked our coder 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 these services. Our reviewer says that 
procedure code 64488-59 is not supported. Our coder reviewer found CPT 64488 is bundled with procedure 
00790 which was billed on the same date by the same provider.  However, a modifier is allowed to unbundle 
the services providing the medical documentation supports the use of the modifier. The medical records 
provided do not include sufficient documentation to support 64488 was performed as a distinct, separate 
procedure from the primary procedure, therefore this service is not eligible for reimbursement consideration. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the injection services rendered on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the TENS device. 
 
You asked the Plan to pre-approve the TENS device. You say that the tens unit should be paid. The Plan denied 
your request. The Plan says the TENS unit is not covered 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 the TENS device. 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 show that the requested TENS device is currently 
medically unnecessary or 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 the TENS device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the TENS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 14, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that your facility does not have access to the 
enrollee's insurance requirements, limitations, or conditions. The Plan denied your request. The Plan says the 
denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the 
ordering practitioner is also out-of-network with the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on January 14, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider on May 7, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. 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 the laboratory services rendered by the out of network (OON) provider on May 7, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased on May 4, 2020 from a non-
contracted provider. 
 
You asked the Plan to pay for the hearing aids. You say that the delegated hearing vendor does not sell the type 
of hearing aids that you need. The Plan denied your request. The Plan says you purchased the hearing aids from 
a provider who is not under contract with the Plan or it's delegated hearing vendor. 
 
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. 
 
Review of the file show that you purchased the hearing aids on May 4, 2020 from a non-contracted provider. 
The health plan contract says that certain services are covered when rendered by a participating provider in the 
Plan's hearing vendor network. The requested provider in this case is not a network provider with the Plan. The 
Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did 
not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these 
items/services. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on May 
4, 2020 from a non-contracted provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous glucose monitor (CGM) 
and supplies you received on July 6, 2020. 
 
You asked the Plan to waive the coinsurance for the CGM and supplies. You say that diabetic supplies should 
be paid at 100%. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the CGM and supplies. According to your contract, the CGM 
and supplies falls within the 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 the continuous glucose monitor (CGM) and supplies you received on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Botox injection you received on 
October 15, 2019. 
 
You asked the Plan to waive the coinsurance for the Botox injection. You say that you paid your $40 office 
visit copayment, so you are not responsible for this charge. The Plan denied your request. The Plan says you 
were charged this coinsurance 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 15% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay 15% coinsurance for the Botox injection. The Botox injection falls within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the Botox injection you received on October 15, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 9, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan 
says coverage of comprehensive genomic profile testing is limited to one test per specimen. 
 
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 the testing at issue was not billed with a correct CPT code. 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 Guardant360 testing provided on May 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the 
UL, UR, LL, and LR quadrants, crowns (D2740) for tooth #'s 6, 12, & 3, retainer crown (D6750) for tooth #11, 
and pontic (D6210) for tooth #10. 
 
You asked the Plan to pre-approve the scalings and planings, crowns, retainer crown, and pontic. You say that 
you have high sensitivity and are in pain. The Plan denied your request. The Plan says the documentation does 
not support that these services are medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the scalings 
and planings, crowns, retainer crown, and pontic when the services are medically necessary and reasonable.  
 
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 scalings and planings, crowns, 
retainer crown, and pontic. Our reviewer says that these services are not medically necessary. Our physician 
reviewer found the provided x-rays do not show any significant bone loss involving four or more teeth in any 
quadrant, and periodontal scalings and root planings are not necessary. Our reviewer found that there is 
insufficient damaged or missing structure of teeth #3, #6 or #12 such that a full coverage crown restoration 
would be needed to strengthen the remaining tooth structure. Tooth #'s 3, 6 and 12 do not show sufficient loss 
to consider full coverage restorations. Our physician reviewer found that tooth #11 has some structural damage, 
but it does not appear to require a full crown restoration to restore it. 
 
 
 
Our reviewer also found that the treatment plan calls for a cantilever pontic for #10 so that #10 could be 
replaced in the arch.  As #7 is also missing, and a partial denture has been approved to replace #5 and #7 which 
would easily be designed to incorporate #10.  As a partial denture is to be fabricated to replace other teeth in 
the upper arch the requested retainer crown for #11 and pontic for #10 are not necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scalings and planings, crowns, retainer crown, and pontic have not been 
met. Therefore, we decided that the Plan does not have to pre-approve periodontal scalings and root planings 
(D4341) of the UL, UR, LL, and LR quadrants, crowns (D2740) for tooth #'s 6, 12, & 3, retainer crown 
(D6750) for tooth #11, and pontic (D6210) for tooth #10.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
April 17, 2020, to April 20, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were not told in 
advance how much this hospital stay would cost. The Plan denied your request. The Plan says the copayment 
you are being charged is correct. 
 
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 $275 
copayment each day for days 1 to 5 for in-network Medicare-covered hospital care.  
 
You have been asked to pay an $825 copayment for your three day inpatient hospital stay ($275 x 3). 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 provided from April 17, 2020, to April 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 4 & 5 and retainer crowns 
(D6750) for tooth #'s 3 & 6. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you had open heart surgery 
and are in pain. You also say that you are taking medications before going to the dentist to have anything done 
for your teeth. The Plan denied your request. The Plan says these services are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the pontics 
and retainer crowns when the services are medically necessary and reasonable.  
 
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 pontics and retainer crowns. Our 
reviewer says that there is no necessity for the requested bridge from tooth #3 to #6. Our physician reviewer 
found the teeth appear to be stable and have sufficient bone support. The treatment plan appears to be 
reasonable but is not the only method of replacing #4 and #5.  
 
Our reviewer found that there has been no showing of a physical or neurological disorder that would prevent 
the use of a removable appliance.  Our physician reviewer also found that although the treatment plan is 
reasonable, the Plan does not provide coverage for this type of appliance unless very specific criteria are met as 
to health issues. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6240) for tooth #'s 4 & 5 and retainer crowns (D6750) for 
tooth #'s 3 & 6.