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

We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 28,
2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you are unhappy with the service
you received by the physician and nurse. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct 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 $40
copayment for each visit with a specialist.
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 visit provided on September 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head rendered on
June 25, 2021.
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 70460 is not separately payable.
The rules say that if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a
modifier is used.
We looked at the file and Medicare rules. The provider submitted a claim for procedure codes 70450 (CT
head/brain without dye) and 70460 (CT head/brain with dye). Code 70450 is a column II code with a modifier
indicator of 0 when billed with column I code 70460. The Plan paid code 70450; therefore, code 70460 is not
separately payable. Therefore, we decided that the Plan does not have to pay for the computed tomography
(CT) scan of the head rendered on June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies provided on April 12, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says incorrect codes were submitted.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
The file shows that codes A4556 and A4630 were billed for transcutaneous electrical nerve stimulators (TENS) supplies. We looked at the file and the rules. The rules say that code A4595 should be used instead. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the supplies provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on September 2, 2021.
You asked the Plan to pay for the crown. You say that your provider contacted the Plan and were told that the Plan would cover 30% and you would be responsible for 70%. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that neither you nor your provider contacted the Plan prior to this date of service to verify 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 crown (D2740) provided on September 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3D rendering services provided on August 20, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The file shows that CPT code 76376 was billed with code 77063. We find that CPT code 76376 may be eligible for payment when billed with this code pair. The claim information does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 3D rendering services provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an OON office visit provided on September
17, 2021.
You asked the Plan to waive the copayment for the OON office visit. You say that the doctor's office informed
you that the provider was in-network. 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 a $65
copayment for provider services in a PCP or specialist office.
You have been asked to pay a $65 copayment for the OON office visit. The OON office visit falls within the
Physician/Practitioner Services, Including Doctor's Office Visits 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 OON office visit provided on September 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head
rendered on September 6, 2021.
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 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 70551 (magnetic resonance imaging, brain stem) and
70544 (MRA head). Code 70544 is a column II code with a modifier indicator of 1 when billed with column I
code 70551. Code 70544 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 magnetic resonance angiography (MRA) of the head
rendered on September 6, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (51875 and 95861), somatosensory testing (95938), the central motor evoked study (95939) and continuous intraoperative neurophysiology monitoring (G0453) provided on June 30, 2021.
You asked the Plan to pay for the intraoperative neuromonitoring services. You say that you would like reconsideration based on the documentation submitted. The Plan denied your request. The Plan says the diagnosis codes billed are not appropriate for the services rendered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT codes 95861, 95938, 95939, 51785 and G0453 are not supported in the medical record. Specifically, the LCAs that are applicable to the services at issue explicitly state that diagnosis codes that are not listed do not support the medical necessity of the service. Diagnosis code T81.40XD is not listed as a covered diagnosis code for any of the CPT codes at issue. Based on this information, we decided that Medicare rules for coverage of the intraoperative neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (51875 and 95861), somatosensory testing (95938), the central motor evoked study (95939) and continuous intraoperative neurophysiology monitoring (G0453) provided on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 25, 2021.
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.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 84520 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 laboratory services rendered on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on July 31, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that the documentation substantiates the necessity of the life vest. The Plan denied your request. The Plan says the 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 file shows that an automatic external defibrillator (LifeVest) was provided. The requested provider in this case is not a network provider with the Plan. 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 durable medical equipment provided on July 31, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme (Q0138).
You asked the Plan to pre-approve Feraheme. You say that this treatment is medically necessary. The Plan denied your request. The Plan says approval of parenteral iron supplement requires documentation of iron deficiency anemia and that oral iron supplementation has been tried and failed or is contraindicated.
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 Feraheme. Our reviewer says that
Feraheme is not medically necessary. Our physician reviewer found records provided from the outpatient clinic or the hospital do not document any iron replacement therapy trials. The enrollee does not have a Medicare-covered indication for the iron treatment. It is not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme (Q0138).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasonic guidance rendered on January 18, 2021.
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 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 pay for these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee underwent trigger point
injections. The medical literature states that ultrasonic guidance is not indicated for trigger point injections. The
services were not medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the ultrasonic guidance rendered on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zostavax vaccine and administration fee provided on
September 13, 2021.
You asked the Plan to pay for the Zostavax vaccine and administration fee. You say that you believe this claim
should be reprocessed and approved for payment. The Plan denied your request. The Plan says this vaccine is
not among those covered under the medical benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zostavax
vaccine and administration fee. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Zostavax
vaccine and administration fee. Therefore, we decided that the Plan does not have to pay for the Zostavax
vaccine and administration fee provided on September 13, 2021.
Benefits for the Zostavax vaccine and administration fee 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis.
You asked the Plan to pre-approve Restasis. You say that Restasis is medically necessary. The Plan denied
your request. The Plan says Restasis is not covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B (for the enrollee's medical condition). Therefore, we decided that the Plan does not have to
pre-approve Restasis.
Benefits for Restasis 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided
from September 18, 2021, to September 19, 2021.
You asked the Plan to waive the copayment for the ER visit. 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 a $65
copayment for emergency services in an emergency room. This copayment is only waived if you are admitted
to the hospital within 24 hours.
The file shows that you were seen in the ER without being admitted.
Therefore, you have been asked to pay a $65 copayment for the ER visit. The ER 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
(ER) visit provided from September 18, 2021, to September 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites of one surface (D2330 x2)
and resin-based composite of three surfaces (D2332) provided on August 19, 2021.
You asked the Plan to pay for the resin-based composites. You say that during the initial visit you advised
because the enrollee was not experiencing any pain with any of her teeth that the plan would be to fix whatever
could be that was covered in order to avoid any out-of-pocket costs for the enrollee, and to fix more after the
new year. You also say that you feel the enrollee should not have to pay for these services. The Plan denied
your request. The Plan says your benefits for these services have been satisfied and the frequency limitation has
been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, restorations (fillings) are limited to two
procedure codes per calendar year. The record shows that the enrollee received a resin-based composite of one
surface (D2330) on June 22, 2021, and a resin-based composite of three surfaces (D2332) on June 27, 2021,
and the enrollee's restorations benefit has been exhausted. Therefore, we decided that the Plan does not have to
pay for the two resin-based composites of one surface (D2330 x2) and resin-based composite of three surfaces
(D2332) provided on August 19, 2021.
Your complaint about the issues regarding the provider's receptionist and not abiding by your wishes to only
provide covered services is not a valid appeal for medical coverage. This part of your complaint is a grievance
that must be answered by the Plan. Medicare does not permit us to make a decision about these types of
complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) services.
You asked the Plan to pre-approve the continued SNF services. You say that you would like reconsideration because the requested SNF care is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of continued SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 continued SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of January 29, 2022. 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 continued SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), teeth extraction on tooth #20 and tooth #18 (D7140, D7210) provided on September 1, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a limited oral evaluation, intraoral radiographic image and teeth extractions. You say that you were misinformed by a representative about your dental benefits, and you did not know you needed a prior authorization in order to see an OON provider. The Plan denied your request. The Plan says preventative and comprehensive dental services are only covered when received by a participating provider. The Plan also says that they reviewed your call history and during a conversation on October 4, 2021, you were advised that the provider you requested was not participating with your Plan. The Plan provided participating dentists in your area.
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. We looked at the file and Medicare rules. The EOC confirms that you must visit a participating provider to receive dental services. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, intraoral radiographic image and teeth extractions have not been met. Specifically, the services were rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220), teeth extraction on tooth #20 and tooth #18 (D7140, D7210) provided on September 1, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on July 27, 2021, by an OON
provider on July 27, 2021.
You asked the Plan to pay for the OON office services. You say that the claims should be reprocessed for
payment. You say that your office has followed all insurance timely filing laws and has provided all the
information requested. The Plan denied your request. The Plan says the services were not urgent or emergent
and were not 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 office services provided on July 27, 2021, by an
OON provider on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for compression stockings identified with code A6533 that were issued on July 15, 2021.
You asked the Plan to pay for compression stockings. You say that you were told by representatives of the Plan that the items at issue would be covered. The Plan denied your request. The Plan says the items at issue are not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for compression stockings identified with code A6533 that were issued on July 15, 2021.
Your complaint about receiving erroneous or incomplete information about your benefits from representatives of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.