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

 
We decided that the Plan does not have to pay for the hearing aids rendered on July 23, 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 the services are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for up 
two TruHearing-branded hearing aids per year. 
 
We looked at the file and the Plan's rules. The file shows that you did not receive hearing aids from a 
TruHearing-branded provider. Based on this information, we decided that the Plan's rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids 
rendered on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01230) provided on November 2, 2019. 
 
You asked the Plan to pay for anesthesia services. You say that this is documented in the records. The Plan 
denied your request. The Plan says this code is not supported. 
 
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 01230 is anesthesia for open procedures involving upper 
two-thirds of femur; not otherwise specified. 
 
We find that CPT code 01230 is not supported in the medical record. Specifically, the submitted anesthesia 
records are not for the billed date of service. Based on this information, we decided that Medicare rules for 
coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for 
anesthesia services (01230) provided on November 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on August 23, 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 the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 chest x-ray rendered on August 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on August 4, 2020. 
 
You asked the Plan to pay for the extraction. You say that you were in extreme pain which you were no longer 
able to tolerate. You say that you were not able to eat or drink. You also say that you were never told that the 
extraction would not be covered. The Plan denied your request. The Plan says the surgical extraction 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. Therefore, we decided that the Plan does not have to pay for the 
surgical extraction (D7210) provided on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an interim partial denture provided on September 1, 2020. 
 
You asked the Plan to pay for interim partial denture. You say that your tooth falling out was an accident and 
going without a front tooth while waiting for an implant is unhealthy. The Plan denied your request. The Plan 
says the denial of payment for this interim partial denture is correct, because this is not covered by the Plan's 
dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an interim 
partial denture provided on September 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and an x-ray 
provided by a participating provider on January 6, 2020, to August 4, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit and an x-ray. You say that you feel like 
the x-ray and diagnostic tests should be included with your office copayment. The Plan denied your request. 
The Plan says the correct copayments have 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 $30 
copayment for physician/practitioner services/specialist office visit and outpatient diagnostic tests/x-rays and 
diagnostic tests/diagnostic test.  
 
You have been asked to pay a $30 copayment for a specialist office visit and a $30 copayment for an x-ray. 
The total amount you are being asked to pay is $120 ($60 (2 office visits) + $60 (2 diagnostic tests/x-ray) = 
$120). A specialist office visit falls within the physician/practitioner services/specialist office visit benefit 
category and an x-ray and diagnostic test falls within the outpatient diagnostic tests/x-rays and diagnostic 
tests/diagnostic test 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 and an x-ray provided by a participating provider on January 6, 2020, to August 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on July 29, 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 70450 is not supported. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 and 70496. Code 70450 is a column II code with a 
modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
computed tomography (CT) scan of the head/brain rendered on July 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on March 9, 2020, to June 9, 2020. You asked the Plan to waive the coinsurance for an injection. You say that you cannot afford this coinsurance. 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 Medicare Part B prescription drugs/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $5,132.70. The total amount you are being asked to pay is $1,026.54 ($5,132.70 x 20% = $1,026.54). 
The correct coinsurance has been applied to the injections that were provided. An injection falls within the 
Medicare Part B prescription drugs/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 
coinsurance for an injection provided by a participating provider on March 9, 2020, to June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ceftriaxone sodium injection and 
methylprednisolone acetate injection provided on March 23, 2020. 
 
You asked the Plan to waive the coinsurance for the ceftriaxone sodium injection and methylprednisolone 
acetate injection. You say that she is being billed for an out-of-network service, but the physician is in-network. 
The Plan denied your request. The Plan says the coinsurance applied 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 20% of the plan-allowed amount for Medicare-Part B covered drugs from an in-network provider. 
 
You have been asked to pay a total of $2.81 for the ceftriaxone sodium injection and methylprednisolone 
acetate injection.  
 
Service Allowed Amount Coinsurance Member Liability 
Ceftriaxone Sodium 
Injection 
$2.36 20% $0.47 
Methylprednisolone 
Acetate Injection 
$11.71 20% $2.34 
TOTAL:   $2.81 
 
 
  
The ceftriaxone sodium injection and methylprednisolone acetate injection fall within the "Medicare Part B 
prescription drugs" benefit category. The records show that the enrollee was charged the in-network rate. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the coinsurance for the ceftriaxone sodium injection and 
methylprednisolone acetate injection provided on March 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram provided on July 29, 2020. 
 
You asked the Plan to pay for the services provided. You say that the clinic letter sent The Plan denied your 
request. The Plan says the claim was 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).  
 
We looked at the file and the rules. You last received a screening mammogram on March 9, 2020. Your plan 
only covers screening mammograms once every 12 months. The services fall within the breast cancer screening 
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 pay for the mammogram provided on July 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy injection and its 
administration provided on July 23, 2020. 
 
You asked the Plan to waive the coinsurance for the chemotherapy injection and its administration. You say 
that you have been receiving this service for the past 20 years and have never received a bill. The Plan denied 
your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each Medicare-covered Part B chemotherapy drugs and the administration of that drug.  
 
You have been asked to pay $1,901.26 which is 20% of the allowed amount for the chemotherapy injection. 
The allowed amount is $9,506.28. ($9,506.28 x 20% = $1,901.26). You have also been asked to pay $18.06 
which is 20% of the allowed amount for its administration. The allowed amount is $90.44. ($90.44 x 20% = 
$18.06).  The chemotherapy injection and its administration fall 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 chemotherapy injection and its administration provided 
on July 23, 2020.  
 
 
 
 
 
Our decision is only about the July 23, 2020 services. If you have any questions about prior years billing, 
please contact the plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on September 9, 2020. 
 
You asked the Plan to pay for the dental services. You say that you have gingivitis. You also say that you need 
a deep cleaning each year. The Plan denied your request. The Plan says scaling in presence of generalized 
moderate or severe gingival inflammation 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. Therefore, we decided that the Plan does not have to pay for scaling in 
presence of generalized moderate or severe gingival inflammation (D4346) provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist office visit provided by a 
participating providers on July 21, 2020. 
 
You asked the Plan to waive the copayment for 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 $20 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $20 copayment for specialist office visit. Specialist office visit falls within the 
physician/practitioner services/specialist 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 specialist office visit provided by a participating provider on July 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-Ray examination provided on January 15, 2020. 
 
You asked the Plan to pay for X-Ray exam. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because the enrollee was 
enrolled in a hospice program on this date of service and therefore the Plan is not responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an X-Ray examination provided on January 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa 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 the criteria requires radiographical evidence to support a diagnosis of osteoarthritis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found a left knee 
radiography notes "none on bone changes to the medial compartment with tricompartmental osteophytes."   
Compendia note the requested medication is "indicated for osteoarthritis pain in patients who have not 
responded to conservative nonpharmacologic therapy ..." The reviewed documentation does not include 
detailed history of non-pharmacologic therapies trialed. Without the support of the documentation, medical 
necessity cannot be determined. 
 
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 Euflexxa for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has been in the acute hospital since 
December 29, 2020 but not getting better. You say if the enrollee continues to stay in the hospital, the enrollee's 
health is in danger and it is not good for his recovery especially being exposed to COVID-19. The Plan denied 
your request. The Plan says based on Medicare guidelines, IRF services do not meet the requirements for 
approval. 
 
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 that based on the documentation provided, the health plan's denial should be 
upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is 
not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician 
evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual physical exam rendered on June 26, 2020. 
 
You asked the Plan to pay for these services. You say that the Plan denied your request. The Plan says the 
services exceed the benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that an annual wellness visit is covered once every 12 
months. 
 
We looked at the file and Medicare rules. The file shows that you received an annual physical exam, not an 
annual wellness exam. This service is not covered by Medicare. Therefore, we decided that the Plan does not 
have to pay for the annual physical exam rendered on June 26, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) (95957) 
unlisted neurological or neuromuscular diagnostic procedure (95999) provided May 15, 2020. 
 
You asked the Plan to pay for special EEG procedures. You say that you are not a contracted provider, 
therefore processing of CPT 95999 should be done manually as to avoid claim adjudication edits. Please review 
enclosed documentation and remit payment accordingly. The Plan denied your request. The Plan says these 
codes are not separately payable as 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 find that CPT code 95957 and 95999 is not supported in the medical record. Specifically, the 
documentation indicates that train of four monitoring was performed. Intraoperative neuromonitoring services 
cannot be performed without train of four testing. This means this component of the procedure is included in 
payment for the overall intraoperative neuromontoring service already paid. CPT code 95955 is billed with 
CPT 95957. CPT 95957 is not separately payable and is denied incidental to CPT 95955. Based on this 
information, we decided that Medicare rules for coverage of special EEG procedures have not been met. 
Therefore, we decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) 
(95957) unlisted neurological or neuromuscular diagnostic procedure (95999) provided May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the walker provided on May 7, 2019 by an out of network 
(OON) provider. 
 
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 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 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 walker provided on May 7, 2019 by an out of 
network (OON) provider.