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

We decided that the Plan does not have to pay for the filling (D2393) provided on July 7, 2021. 
 
You asked the Plan to pay for the dental service. You say that you are being charged beyond the $0 copayment 
because of an out of network dentist status. You say that the service was covered when the provider requested 
the plan estimate. You also say that now the plan is telling the provider to charge you. The Plan denied your 
request. The Plan says the claim was processed correctly. The Plan also says that out of network providers may 
bill you for any amount greater than what the plan pays the provider. 
 
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. Based on this information, we decided that the Plan's rules for 
coverage of the dental service have not been met. Specifically, out of network providers may bill you for any 
amount greater than what the plan pays. The record shows that the Plan paid the full allowed amount, $143. 
The record shows that the provider billed the service at $455. $455 - $143 = $312. This 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 filling (D2393) provided on July 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services (58571) provided on April 26, 2021. 
 
You asked the Plan to pay for the surgery services. You say that this surgery should be compensated at the in-
network rate. The Plan denied your request. The Plan says certain providers are ineligible to enroll in the 
Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the surgery services (58571) provided on 
April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a preventive procedure (D1999), intraoral - periapical first 
radiographic image (D0220), core buildup (D2950), and a crown - porcelain/ceramic (D2740), provided on 
September 1, 2020, and October 6, 2020. 
 
You asked the Plan to pay for a preventive procedure, intraoral - periapical first radiographic image, core 
buildup, and a crown - porcelain/ceramic. You say that the services should be covered. The Plan denied your 
request. The Plan says the requested services are not covered 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 preventive procedure (D1999), intraoral - 
periapical first radiographic image (D0220), core buildup (D2950), and a crown - porcelain/ceramic (D2740), 
provided on September 1, 2020, and October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and laboratory testing provided on April 14, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for office visit and lab test. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because this 
provider is out-of-network with the Plan and 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 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 an office visit and laboratory testing provided on 
April 14, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hemochromatosis DNA gene analysis. 
 
You asked the Plan to pre-approve the genetic testing. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that hemochromatosis gene analysis is covered for the 
indications established in the applicable Local Coverage Article. 
 
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 genetic testing. Our reviewer says 
that the requested genetic testing is not medically reasonable and necessary. Our physician reviewer found that 
the enrollee is an 84-year-old male with rheumatoid arthritis for which he takes Humira. He was recently tested 
to find a low hemoglobin and high ferritin (772) with a normal serum iron level and percent saturation of 35%. 
The ferritin being elevated was new for the enrollee. Hemochromatosis DNA Mutation Analysis was 
performed. Based on the Medicare criteria for DNA testing for hemochromatosis, this enrollee does not meet 
the criteria. The transferrin saturation is not over 45% and the high ferritin was new suggesting inflammation as 
the cause, not hemochromatosis. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve hemochromatosis DNA gene analysis
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed 6 months of 
conservative approaches. The Plan denied your request. The Plan says there is not enough medical evidence 
that shows the procedure is safe and helpful as standard treatment options. 
 
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 is being treated for spinal stenosis, lumbar region, with neurogenic 
claudication. He presented with low back radiating down bilateral legs along with bilateral knee pain that has 
been ongoing for over 10 years. It is constant, sharp, severe, aching, bruising pain which is worse with standing 
and walking and alleviated with rest. He notes numbness and weakness in his legs. He ambulates with a cane. 
Pain is rated as a 9 of 0-10. The exam reveals positive facet loading maneuvers, lumbar flexion and extension 
eliciting painful responses. There is normal strength noted and straight leg raise is negative bilaterally. Deep 
tendon reflexes are symmetric bilateral lower extremities.  
However, current evidence based medical guideline and peer reviewed literature do not fully support the spinal 
decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large 
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical 
condition. There is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion 
interspinous stabilization device at L4-5 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 an interspinous stabilization device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee had 80-90% pain relief. 
The Plan denied your request. The Plan says the documentation does not show the criteria are met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are 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 a history of low back pain secondary to lumbar spondylosis. She has been 
treated with medical therapy and underwent a previous radiofrequency ablation (RFA). The request is for a 
repeat RFA. In this case, per the documentation, the benefit of the initial RFA was not greater than 50% 
improvement. The review has determined that the records do not show that the coverage criteria have been met. 
Therefore, the requested RFA 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 radiofrequency ablation services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on February 24, 2020. 
 
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers. You 
say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an occupational therapy assistant on February 24, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a polysomnogram (sleep study) (95810) and CPAP (continuous 
positive airway pressure) titration (adjustment) study (95811). 
 
You asked the Plan to pre-approve the sleep study. You say that the enrollee as suspected sleep arousal disorder 
in addition to epilepsy. You say that to confirm this diagnosis, a formal sleep study needs to be obtained to look 
for any sleep related issues that could be causing the enrollee's frequent awakenings. The Plan denied your 
request. The Plan says that the requested services do not meet the criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that the evidence is sufficient to determine that the results 
of the sleep tests identified below can be used by a beneficiary's treating physician to diagnose obstructive 
sleep apnea (OSA), that the use of such sleep testing technologies demonstrates improved health outcomes in 
Medicare beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus 
reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the sleep study. Our reviewer says that 
the sleep study is medically necessary. Our physician reviewer found the provided documentation indicates that 
a sleep arousal disorder is suspected, but atypical seizures need to be excluded. The reviewer found that the 
enrollee does not have symptoms of obstructive sleep apnea (OSA). However, the reviewer found that 
diagnosis is possible and therefore the positive airway pressure (PAP) titration is also reasonable. The reviewer 
found that nocturnal electroencephalography (EEG) will help exclude seizures as a cause for these episodes. 
Therefore, the reviewer found that the requested studies are medically reasonable and 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 sleep study have been met. Therefore, we decided that the Plan has to pre-
approve a polysomnogram (sleep study) (95810) and CPAP (continuous positive airway pressure) titration 
(adjustment) study (95811).  

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on July 
3, 2021. 
 
You asked the Plan to waive the copayment for urgently needed services. You say that you were not given the 
correct prescription and feel that you should not be held responsible for the charges. 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 $65 
copayment for urgently needed services.  
 
You have been asked to pay the allowed amount of $48.67, which is less than the $65 copayment for urgently 
needed services. Urgently needed services fall 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 waive the copayment for urgently needed services provided on July 3, 2021.  
 
We note your complaint that you are unhappy with the service you received. Your complaint is a grievance that 
must be answered by the health plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
June 28, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you do not feel as though you should 
have to pay this copayment because you were not treated properly for your back pain. The Plan denied your 
request. The Plan says you were charged this copayment 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 $90 
copayment for emergency room visits.  
 
You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of your 
satisfaction with the services received. 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 room (ER) visit you had on June 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on February 15, 2021. 
 
You asked the Plan to pay for the outpatient service. You say that you provided a corrected claim with the 
proper modifier. You say that the claim denied again. The Plan denied your request. The Plan says the 
enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits 
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it 
is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper 
billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 9, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the office visit 
(99214) provided on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
June 24, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you have been going 
to this dentist for several years and not planning to change. You say that you were informed all the doctors you 
used were in the system and you should be reimbursed for the services. The Plan denied your request. The Plan 
says there is no coverage for services rendered by an out-of-network provider. 
 
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 
periodic oral evaluation and prophylaxis provided on June 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from January 15, 2021, to January 20, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you thought that all 
cost sharing during the COVID-19 pandemic was waived. The Plan denied your request. The Plan says you 
were charged this copayment correctly. The Plan says that the only cost sharing that was waived was for office-
based services with primary care or specialists from May 11, 2020, to September 30, 2020. 
 
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 $295 
copayment per day for days 1-5, and a $0 copayment for additional days for inpatient hospital care.  
 
Records show that you were in the hospital for 6 days.  You were charged a copayment for $295 per day for the 
first 5 days, for a total of $1475.  You were not charged a copayment for the sixth day of your stay in 
accordance with your contract. The Plan's own website explicitly states that if you get sick with COVID-19, 
cost sharing will be according to your benefit plan.  You will be responsible for any copay, coinsurance, 
deductible, or out-of-network costs.  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 inpatient hospital 
services you received from January 15, 2021, to January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99223) subsequent hospital care (99233) 
hospital discharge day management (99239) provided May 3, 2020 to May 8, 2020. 
 
You asked the Plan to pay for the hospital care. You say that you do not believe that this provider should be 
penalized for the enrollee's failure to provide correct insurance information. The Plan denied your request. The 
Plan says this claim was received past the timely filing limitations. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the hospital care was not filed until June 15, 2021. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for initial hospital care (99223) subsequent hospital care (99233) hospital discharge 
day management (99239) provided May 3, 2020 to May 8, 2020.