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

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on August 18, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because this service was medically necessary and you were told it would be covered. The Plan denied your request. The Plan says out-of-network virtual care is not a covered benefit.
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 Virtual Care visits are not covered when the services are provided out-of-network. We looked at your request, the file and Medicare rules. Based on this information we have determined that Medicare criteria for coverage have not been met. Specifically, the Plan explicitly states that virtual care is only covered when rendered in-network. The record indicates that this virtual psychotherapy service was not
rendered in-network. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837) provided on August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the arm brace and cover provided on August 24, 2021.
You asked the Plan to waive the coinsurance for the arm brace and cover. You say that you should not be charged for an arm brace because they were necessary for your broken arm. The Plan denied your request. The Plan says you have been asked to pay 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 all other Medicare-covered in-network prosthetic devices and supplies.
You have been asked to pay $79.27 which is 20% of the allowed amount for the arm brace and cover. The allowed amount is $396.38. ($396.38 x 20% = $79.27). The arm brace and cover fall within the "Prosthetic devices and related supplies" 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 arm brace and cover provided on August 24, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and
intraoral - periapical first radiographic image (D0220) provided October 7, 2021.
You asked the Plan to pay for the limited oral exam and periapical x-ray. You say that you were not told that
you would have to pay extra. The Plan denied your request. The Plan says these services are not covered under
your 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 the limited oral evaluation - problem focused
(D0140) and intraoral - periapical first radiographic image (D0220) provided October 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hyaluronan or derivative, synvisc or
synvisc-one, for intra-articular injection (J7325) rendered on July 27, 2021.
You asked the Plan to waive the coinsurance for hyaluronan or derivative, synvisc or synvisc-one, for intra-
articular injection. The Plan denied your request. The Plan says you were 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a 20% coinsurance for Medicare Part B Prescription Drugs.
You have been asked to pay $104.50 in coinsurance, which is 20% of the allowed amount for Hyaluronan or
derivative, synvisc or synvisc-one, for intra-articular injection ($522.48 allowed amount x 20% = $104.50).
Hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injections fall within the Medicare Part B
Prescription Drugs benefit category. 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
hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection (J7325) rendered on July 27,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve ablation services.
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative
measures. The Plan denied your request. The Plan says this type of injection is considered experimental.
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 requested services. Our physician
reviewer found that the enrollee has a history of diabetic neuropathy in both feet and a history of left chronic
knee pain due to osteoarthritis, s/p right total knee arthroplasty. Genicular nerve blocks and genicular nerve
radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic
knee pain. The review has determined that the requested radiofrequency ablation of the left knee is 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 genicular nerve ablation services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on January 23, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be covered as you stayed overnight. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
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 $125 copayment for Emergency care.
You have been asked to pay a $125 copayment for an emergency room visit. The record indicates that you were not admitted during your stay. 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 provided on January 23, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an intraoral imaging (D0220) provided by a participating provider on September 28, 2021.
You asked the Plan to pay for a limited oral evaluation and an intraoral imaging. You say that you would like the Plan to pay for this because the services were medically necessary. The Plan denied your request. The Plan says D0140 and D0220 are not covered 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 a limited oral evaluation (D0140), and an intraoral imaging (D0220) provided by a participating provider on September 28, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on August 16,
2021.
You asked the Plan to waive the copayment for the endoscopy. You say that you were charged $200 out-of-
pocket for the procedure which was filed under an out-of-network facility. The Plan denied your request. The
Plan says you have been asked to pay 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 a $200
copayment for an in-network ambulatory surgical center.
You have been asked to pay a $200 copayment for the endoscopy. The endoscopy falls within the "Outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit
category. The record shows you were billed by a facility fee by the in-network ambulatory surgical center
facility.
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 endoscopy provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
October 12, 2021.
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says the member's vision allowance of $200 was applied to the claim leaving a balance of $75, which is the member's responsibility.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that your vision allowance of $200 was applied to the claim leaving a balance of $75, which is your responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on October 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998),
provided on May 13, 2021.
You asked the Plan to pay for the ambulance service. You say that the ground transport was not used due to the
helicopter being called. You also say that the enrollee was airlifted to the hospital. The Plan denied your
request. The Plan says there was no ground transport provided on the date of service in this case. The Plan also
says that since there was no ground transport provided there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on May 13, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no
transport (A0998), provided on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80069, 82043, 83036)
rendered by the out-of-network (OON) provider on September 1, 2021.
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 had network providers available
who could have provided 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 (36415, 80069, 82043, 83036) rendered by the out-of-
network (OON) provider on September 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy, flexible; diagnostic (45378) provided September 10, 2021.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that your provider told you the procedure was preventative. The Plan denied your request. The Plan says the copyament was 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). Your contract with the Plan clearly says that you must pay a $225 copayment for each Medicare-covered ambulatory surgical center visit. 

You have been asked to pay a $225 copayment for the diagnostic colonoscopy. The medical records provided show that you have a personal history of colonic polyps. This means the colonoscopy was correctly billed as a diagnostic colonoscopy. The diagnostic colonoscopy falls within the Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers 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 the colonoscopy, flexible; diagnostic (45378) provided September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine (90750, 90471) provided September 21, 2021.
You asked the Plan to pay for the shingles vaccine. You say that the shingles vaccine should be covered. The Plan denied your request. The Plan says this vaccine is not eligible for coverage under the Part B medical benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for a shingles vaccine (90750, 90471) provided September 21, 2021.
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrocentesis (20610) and fluoroscopic guidance for needle placement (77002) provided by an out-of-network provider on October 5, 2020.
You asked the Plan to pay for the arthrocentesis (20610) and fluoroscopic guidance for needle placement (77002). You say that the medical records prove the medical necessity and payment should be considered. The Plan denied your request. The Plan says CPT code 20610 will remain denied since the provider is not a network provider with the Plan. The Plan also says that since 20610 is denied, code 77002 will also remain denied.
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 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 arthrocentesis (20610) and fluoroscopic guidance for needle placement (77002) provided by an out-of-network provider on October 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent or approved in advance.
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 had network providers available who could have provided 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 laboratory services provided on August 16, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve repeat epidural steroid injections.
You asked the Plan to pre-approve the repeat epidural steroid injections. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says that the documentation does not show that the frequency limits will not be exceeded.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pre-approve the repeat epidural steroid injections. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case.
Our physician reviewer found the member has radiculopathy and has not responded to conservative therapy. The member meets LCD criteria for coverage. 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 repeat epidural steroid injections have been met. Therefore, we decided that the Plan has to pre-approve repeat epidural steroid injections.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) and therapeutic parenteral drugs, two or more administrations, different medications (D9612) provided on August 30, 2021.
You asked the Plan to pay for the dental services. You say that you could not find a specialist within 50 miles that accepted your insurance. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services received out of network are not covered.
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 dental services you received are not among those covered under this benefit when performed out of network. Therefore, we decided that the Plan
does not have to pay for the surgical extraction (D7210) and therapeutic parenteral drugs, two or more administrations, different medications (D9612) provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for core build up (D2950) for tooth # 12 and crown (D2740) for tooth # 12 provided on October 4, 2021.

You asked the Plan to pay for the dental services. You say that these services were approved. You say that the approval form did not indicate that the services would only be covered up to $1,000. You also say that you do not have money to pay this bill. The Plan denied your request. The Plan says there is a maximum benefit of $1,000 for comprehensive dental services. The Plan also says that the maximum benefit 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 and the services are listed as covered, the maximum benefit has been exhausted.

Procedure Code
Allowed Amount
Plan Paid
Your Responsibility

D3310
$462
$369.60
$92.40

D2950 (# 11)
$195
$97.50
$97.50

D2740 (# 11)
$872
$436
$436

D3320
$536
$287.30
$248.70

D2950 (# 12)
$195
$0
$195

D2740 (# 12)
$872
$0
$872

TOTAL:
$1,190.40
$1,941.60

Therefore, we decided that the Plan does not have to pay for core build up (D2950) for tooth # 12 and crown (D2740) for tooth # 12 provided on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Gastric Peroral Endoscopic Myotomy (G-POEM)
(43999).
You asked the Plan to pre-approve the G-POEM. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service is 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 G-POEM. Our reviewer says that
the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer
found this procedure does not yet have sufficient high quality evidence to support its regular use in the setting
of gastroparesis or GERD without achalasia, such as in this case.
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 G-POEM have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Gastric Peroral Endoscopic Myotomy (G-POEM) (43999).