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

We decided that the Plan does not have to pay for the additional periapical x-ray (D0230) and the unspecified 
preventive service (D1999) provided on July 14, 2020. 
 
You asked the Plan to pay for the dental services. You say that there was no reason that the second x-ray 
needed to be taken. You say that the rest of the information was submitted online. You also say that you do not 
have an extra $20. The Plan denied your request. The Plan says 1 periapical x-ray per calendar year is covered. 
The Plan says that the frequency limit for this service has been exceeded. The Plan also says that you are not 
responsible for the charge associated with the unspecified preventive 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 frequency limit for this service has 
been exceeded. The record shows that the Plan paid for 1 periapical x-ray that you received on the date of 
service in this appeal, thus exhausting the benefit. Therefore, we decided that the Plan does not have to pay for 
the additional periapical x-ray (D0230) and the unspecified preventive service (D1999) provided on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no record of the amount of relief that was present after the second injection. 
 
The Plan follows Medicare rules. Medicare rules say that radiofrequency neurotomy is only covered under 
certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has chronic low back pain. She has had 2 sets of diagnostic MBBs. The first 
set gave her 70% relief, and for the second set, degree and duration of pain relief is not detailed in the notes. 
The criteria require greater than 80% pain relief.  This was not met. 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on July 21, 2020. 
 
You asked the Plan to pay for the dental service. You say that at least some of the services you received should be 
covered under your medical or dental plan. The Plan denied your request. The Plan says the bone replacement graft 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 services you are asking the Plan to pay for involve the care, treatment, 
filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services 
that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft (D7953) provided on July 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Shoulder Dynasplint (E1840). 
 
You asked the Plan to pre-approve a Shoulder Dynasplint. You say that the requested item is medically 
necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met. 
 
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 a Shoulder Dynasplint. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested Shoulder Dynasplint is not medically necessary for the enrollee's 
adhesive capsulitis of the shoulder per Medicare rules, which indicate that medically necessary services are 
those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically 
necessary services include services to improve the functioning of a malformed body member. There is 
insufficient evidence in the scientific literature regarding the safety and effectiveness of this device for the 
enrollee's shoulder condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Shoulder Dynasplint have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Shoulder Dynasplint (E1840).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for cataract surgery provided on March 2, 2020. You asked the Plan to waive the cost share for cataract surgery. You say that you were informed you would only have a $250 copayment. You say that you shouldn't be obligated to pay the deductible. The Plan denied your request. The Plan says the cost share applied correctly. 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 your deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Your contract with the Plan also says that you must pay a $250 copayment for Medicare-covered surgery or other services provided to you at an in-ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. The item or service you asked the Plan to waive the cost share for falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to outpatient surgery. The deductible is a contractual obligation that had not been met at the time cataract surgery was received on March 2, 2020. Therefore, $500 has been applied to meet your deductible. Since the $500 deductible was met, you have also been asked to pay a $250 copayment for the cataract surgery. 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 cost share for cataract surgery provided on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe additional periapical x-ray (D0230) provided on July 2, 2020.You asked the Plan to pay forthe additional periapical x-ray. You say that you verified your benefits multiple times prior to your appointment. You say that you wanted to be informed of any out of pocket expenses prior to the services being provider. You also say that you are disabled and have insurance for a reason.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that there are in network providers at that location. The Plan also says that the frequency limit of 1 periapical x-ray per calendar year has been exhausted.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 frequency limit of 1 periapical x-ray per calendar year has been exhausted. The record shows that the Plan paid for 1 periapical x-ray that you received on this date of service, thus exhausting the benefit.Therefore, we decided that the Plan does not have to pay forthe additional periapical x-ray (D0230) provided on July 2, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on May 7, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 physician services provided on May 7, 2020 by an 
out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided from June 
5, 2020 through June 18, 2020. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that the enrollee's benefit is exhausted. 
 
The Plan must follow Medicare rules. The rules say that there is a lifetime maximum of 190 days on inpatient 
psychiatric hospital services available to any beneficiary and once an individual receives benefits for 190 days 
of care in a psychiatric hospital, no further benefits of that type are available to that individual.  
 
The file shows that the enrollee received 190 days of inpatient psychiatric hospital services.  
 
Although the enrollee may still have needed inpatient psychiatric hospital services, the Plan is not required to 
pay for more than 190 days of inpatient psychiatric hospital services. Therefore, we decided that the Plan does 
not have to pay for the inpatient psychiatric hospital services provided from June 5, 2020 through June 18, 
2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Emergency Room visit (99282) 
provided February 11, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Emergency Care.  
 
You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency Care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
Emergency Room visit (99282) provided February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on August 31, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that these services were medically needed. You say 
that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan 
says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network. 
 
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 physician services provided on August 31, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cryosurgery of the prostate to treat benign prostatic hyperplasia (BPH). You asked the Plan to pre-approve the cryosurgery. You say that it is felt that this is an approved treatment for 
this condition. There is nothing to indicate that diagnosis code D29.1 is not allowed for this procedure. The Plan denied your request. The Plan says this is not covered for this condition. 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 cryosurgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has BPH and lower urinary tract symptoms. He has not been treated with any medications or other procedures. Cryosurgery of the prostate gland is not indicated for the treatment of BPH. It is indicated for early stage prostate cancer. The 2020 AUA Guidelines do not recommend cryosurgery for the treatment of BPH. 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 cryosurgery have not been met. Therefore, we decided that the Plan does not  have to pre-approve cryosurgery of the prostate to treat benign prostatic hyperplasia (BPH).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee. 
 
You asked the Plan to pre-approve the additional trips. You say that you have to see providers, and have reached the limit 
of transportation benefits. The Plan denied your request. The Plan says the benefit limit has been exceeded. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a 
maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on 
June 10, 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 diagnosis is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that a PET scan is covered when specific criteria are 
met. 
 
We looked at the file and Medicare rules. There is no documentation to support that the PET scan meets the 
criteria for coverage. 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 positron emission 
tomography (PET) scan rendered on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for open or surgical arthroscopic procedures of the 
shoulder (01630) provided by the appealing provider. 
 
You asked the Plan to pay for anesthesia for open or surgical arthroscopic procedures of the shoulder. You say 
that the service was provided and payment should be rendered. The Plan denied your request. The Plan says 
based on the documentation provided, the claim was processed correctly. 
 
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 01630 is anesthesia for open or surgical arthroscopic 
procedures of the shoulder. 
 
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 anesthesia for open or surgical arthroscopic 
procedures of the shoulder. Our reviewer says that the service is not supported by the medical records. Our 
coding reviewer found the documentation did not include an anesthesia report to confirm this services was 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of anesthesia for open or surgical arthroscopic procedures of the shoulder have not 
been met. Therefore, we decided that the Plan does not have to pay for anesthesia for open or surgical 
arthroscopic procedures of the shoulder (01630) provided by the appealing provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the unspecified preventive service (D1999) 
provided. 
 
You asked the Plan to reimburse you for the dental services. The Plan denied your request. The Plan says the 
unspecified preventive services 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 Plans 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. The record shows that the provider's office confirmed that this code 
was being used for an infection control fee related to Covid-19, which is not a covered service either. 
Therefore, we decided that the Plan does not have to reimburse you for the unspecified preventive service 
(D1999) provided.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider. You asked the Plan to pre-approve OON services. You say that the requested provider has a multidisciplinary program that is not available in-network. The Plan denied your request. The Plan says in-network providers can meet your needs. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider at issue in this case is not a network provider with the Plan. 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 OON services. Our reviewer says that the criteria for coverage of OON services have not been met. Our physician reviewer found the management of dementia is otherwise largely symptomatic in nature. Ongoing management can be provided by the appropriate specialists within your current network. The Plan has demonstrated that they have multiple specialties available (Neurology, psychiatry, geriatric psychiatry, psychology) in network. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OON services have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve OON services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 11, 
2020 and billed under code 27786. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do not support the services 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. 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 this service. Our reviewer says that Medicare billing criteria are not met. The medical records 
do not contain documentation of closed treatment of distal fibular fracture (lateral malleolus); without 
manipulation. Our physician reviewer found the records provided do not support the services billed. We looked 
at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay 
for physician services provided to the enrollee on March 11, 2020 and billed under code 27786.
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 26, 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 separately payable. 
 
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 26, 2020.