Persius/hicric huggingface dataset:
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 January 20, 2021.
You asked the Plan to pay for the ambulance service. You say that you received your second coronavirus vaccine. You say that you had a reaction to it. You say that the nurse called over an emergency medical service (EMS) personnel. You say that after a short wait you were released. You also say that you should not be responsible for this bill as you were not informed there was a fee for this service. The Plan denied your request. The Plan says ambulance treatment with no transportation is not covered by Medicare.
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 January 30, 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 January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and
D5120).
You asked the Plan to pre-approve the complete upper and lower denture (D5110 and D5120). You say that the
impression was started on November 26, 2019 but the patient was not called back to the office until July 21,
2021. You say that try ins were not done and the approval should be reconsidered. The Plan denied your
request. The Plan says dentures have a frequency of one procedure every five years.
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, there is also a maximum benefit of one
complete upper and lower denture every five plan years. The Plan paid for a complete upper and lower denture
on December 13, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to
pre-approve the complete upper and lower denture (D5110 and D5120).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography coded 70450 and 72125 and the x-ray coded 73522 provided on February 4, 2021.
You asked the Plan to pay for the computed tomography and the x-ray. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 70450, 72125, and 73522 are not supported in the medical record. Specifically, the documentation does not support the codes billed for this date of service. The medical records submitted for these services were for a different date of service (February 1, 2021). Based on this information, we decided that Medicare rules for coverage of the computed tomography and the x-ray have not been met.
Therefore, we decided that the Plan does not have to pay for the computed tomography coded 70450 and 72125 and the x-ray coded 73522 provided on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia provided on May 25, 2021.
You asked the Plan to pay for the dental services. You say that the claim was billed appropriately. The Plan
denied your request. The Plan says the diagnosis on the claim is not covered by the enrollee's plan.
Medicare generally does not cover dental services. The Plan follows the same rule.
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 anesthesia provided on May
25, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Seroquel XR tab.
You asked the Plan to pre-approve Seroquel XR. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Seroquel XR tab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4341) for the upper left and lower left quadrants provided on February 25, 2021.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says scaling and root planing is covered for 1 procedure per quadrant, every 2 plan years. The Plan also says that the frequency limit 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. The Plan covers the dental services when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the frequency limit has been exceeded. The record shows that the Plan paid for scaling and root planing for the upper left and lower left quadrants that you received on April 29, 2019. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4341) for the upper left and lower left quadrants provided on February 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (sodium hyaluronate) injections for the knee.
You asked the Plan to pre-approve the Euflexxa injections. You say that the enrollee would benefit from this treatment. The Plan denied your request. The Plan says there has not been a clear trial of conservative therapy, including physical therapy, for the enrollee's knee pain.
The Plan follows Medicare rules. Medicare rules say that Euflexxa may be covered when there has been a failure of pharmacological and non-pharmacological treatments of the knee condition. 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 Euflexxa injections. Our reviewer says that the requested Euflexxa injections are not considered medically reasonable and necessary. Our physician reviewer found there is no documentation provided indicating that the enrollee had an inadequate response to conservative non-pharmacologic therapy. Based on the documentation, no physical therapy has been completed. The review has determined that the enrollee does not meet criteria for treatment with Euflexxa 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 Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (sodium hyaluronate) injections for the knee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial comprehensive preventive medicine evaluation
provided on December 22, 2020, by an OON provider.
You asked the Plan to pay for the initial comprehensive preventive medicine evaluation. You say that the
service was medically necessary. The Plan denied your request. The Plan says no prior authorization was
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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the initial comprehensive preventive medicine evaluation
provided on December 22, 2020, by an OON provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Monoferric injection provided on May 15, 2021.
You asked the Plan to pay for the Monoferric injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the Monoferric injection is not supported in the medical record. Specifically, the documentation does not include a diagnosis or documentation of laboratory work to support that the injection services rendered were necessary. Based on this information, we decided that Medicare rules for coverage of the Monoferric injection have not been met. Therefore, we decided that the Plan does not have to pay for the Monoferric injection provided on May 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), removal of residual tooth roots (D7250 x 3), and inhalation of nitrous oxide (D9230) provided from April 13, 2021, to May 4, 2021.
You asked the Plan to pay for the dental services. You say that you paid for the oral evaluation because the frequency limit was reached. You say that the provider's office advised insurance would pay $300.80 for each tooth. You say that paying for these services is a hardship on your family. You also say that there must be more that can be paid for these services. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that the frequency limit has been exceeded. The Plan says that dental services performed out of network have a higher cost share. The Plan also says that the coinsurance was applied correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the frequency limit for limited oral evaluation has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on February 15, 2021. Additionally, out of network providers may bill you for any amount greater than what the plan pays. Coinsurance is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), removal of residual tooth roots (D7250 x 3), and inhalation of nitrous oxide (D9230) provided from April 13, 2021, to May 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0429, A0425) provided on April 29, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that this ambulance ride was medically necessary because you were experiencing COVID-19 symptoms. The Plan denied your request. The Plan says these services were covered, and your copayment was assessed in accordance with your contract.
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 $285 copayment for each one-way ambulance trip. You have been asked to pay a $285 copayment for the ambulance services. The policies in place due to the current public health emergency do not waive or change ambulance copays for medically necessary services provided due to COVID-19. 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 emergency ambulance transportation services (A0429, A0425) provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 2, 2021.
You asked the Plan to pay for the comprehensive oral evaluation (D0150). You say that you changed to an in-network provider to eliminate the out-of-pocket expenses. You say that there is always an evaluation when starting with a new dentist and the charge should be covered. The Plan denied your request. The Plan says procedure code D0150 was previously received on February 6, 2020 and paid for.
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, you also have a maximum benefit of one comprehensive oral evaluation every three years. The Plan paid for the comprehensive oral evaluation provided on February 6, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for a patient of an extreme age (99100)
provided on October 1, 2020.
You asked the Plan to pay for the anesthesia for a patient of an extreme age. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for CPT
code 99100 is bundled into another procedure.
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 99100 is anesthesia for patient of extreme age, younger
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).
We find that CPT code 99100 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code 99100 has a status indicator of B. This means that payment for CPT code 99100 is bundled into the
payment for another procedure. CPT code 99100 cannot be billed separately. Based on this information, we
decided that Medicare rules for coverage of the anesthesia for a patient of an extreme age have not been met.
Therefore, we decided that the Plan does not have to pay for the anesthesia for a patient of an extreme age
(99100) provided on October 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computer-assisted navigation during right knee surgery.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is lack of evidence to support use of computer-assisted navigation over conventional total knee arthroplasty technique.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Current evidence based medical literature does not support the routine use of computer-assisted navigated total knee arthroplasty over conventional total knee arthroplasty. There is a lack of ultimate outcome differences regarding pain reduction and functional improvement with the request as compared to conventional total knee arthroplasty. Our physician reviewer found that your condition does not meet criteria for coverage of these services. 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 pre-approve computer-assisted navigation during right knee surgery.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on April 17,
2021.
You asked the Plan to reduce the copayment for the urgent care visit. You say that you would like the
copayment reduced because the urgent care visit was pre-emptive. 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 $65
copayment for each Medicare-covered urgent care facility visit.
You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the
"Urgently needed services" 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 reduce the copayment for the urgent
care visit provided on April 17, 2021.
Your complaint about the unfair benefit design 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for additional selective angiography, after basic study, list
separately in addition to code for primary procedure (75774) angiography, visceral, selective or supraselective
(with or without flush aortogram), radiological supervision and interpretation (75726) provided April 1, 2021.
You asked the Plan to pay for the surgical procedure. You say that please notice CPT codes willed with XU
modifiers. Per CCI coding guidelines, this modifier separates these from being considered included in any other
charges billed. Notes attached for review and reconsideration for payment. The Plan denied your request. The
Plan says these codes are inclusive to another billed code.
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 have confirmed that codes
75574 and 75726 has a bundled relationship with code 37243 and cannot be paid as billed. These codes cannot
be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for additional selective angiography, after basic study,
list separately in addition to code for primary procedure (75774) angiography, visceral, selective or
supraselective (with or without flush aortogram), radiological supervision and interpretation (75726) provided
April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on April 23, 2021 and May 26, 2021.
You asked the Plan to pay for the dental services. You say that you were told there were no in-network dentists, so you decided to remain at your office. You say that you are asking for $816 for April 23, 2021 and $2,823 for May 26, 2021. The Plan denied your request. The Plan says out-of-network dental services 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on April 23, 2021 and May 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you require
transportation for upcoming surgery. The Plan denied your request. The Plan says that this request exceeds the
transportation benefit limit.
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 twenty-four (24) 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
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for computed tomography (CT) abdomen and
pelvis (74176) provided May 21, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you were discharged from
the hospital and was home for 2 1/2 hours when your home health nurse saw how sick you were and suggested
calling an ambulance. You were readmitted to the hospital. You only did what you had to do. The Plan denied
your request. The Plan says the claim was processed with the correct copayment 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 $225
copay for advanced imaging services.
You have been asked to pay $225 copay for the diagnostic service. The diagnostic service falls within the
Outpatient diagnostic tests and therapeutic services and 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 copayment for computed tomography (CT) abdomen and pelvis (74176) provided May 21, 2021.