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

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on June 2, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that a Plan representative advised that you could be treated for a toothache by the provider you went 
to. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did 
not contact the Plan prior to this date of service to verify benefits and provider eligibility. 
 
  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 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on June 
2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0679) provided May 10, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that you believe you 
have a misunderstanding on the use of these place of service (POS) codes. You are requesting to have these claims re-evaluated. The Plan denied your request. The Plan says pneumatic compression device is not covered 
by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous 
thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. 
In this case the enrollee used the equipment in the facility during and/or after surgery. Payment for this service 
would have been included under the facility claim. Payment for this service is the responsibility of the facility 
or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for a pneumatic 
compression device (E0675) and segmental pneumatic appliance (E0679) provided May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3320) provided on April 22, 2021, by 
a non-participating provider. 
 
You asked the Plan to pay for endodontic therapy. You say that you were never made aware that your dental 
coverage would be changing the in-network providers. The Plan denied your request. The Plan says you must 
use network providers to get your medical care and services. 
 
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 endodontic 
therapy when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The records show that you received services from a non-participating 
provider, therefore, you are responsible for 100% of the cost for dental services. Based on this information, we 
decided that the Plan's rules for coverage of endodontic therapy have not been met.  
 
 
  
 
Therefore, we decided that the Plan does not have to pay for endodontic therapy (D3320) provided on April 22, 
2021, by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for 26 physical therapy visits rendered at an 
in-network outpatient hospital from June 1, 2021, to July 30, 2021. 
 
You asked the Plan to reduce the copayment for physical therapy services. You say that prior to enrolling in the 
Plan, you were told physical therapy would have a $15 copayment. You feel the Plan should honor that amount 
for the duration of treatment. You say you cannot afford the bill. The Plan denied your request. The Plan says 
the copayment was applied correctly according to your benefits. The Plan stated a grievance was opened as a 
result of a phone call to the Plan on April 28, 2021, regarding a bill for services received in March. The Plan 
says you claimed to have been misquoted. The Plan responded to the grievance by approving a one-time 
copayment reduction for those visits as a good faith gesture. However, the Plan informed you during the phone 
call and in subsequent letters that the correct copayment for services at the chosen facility is $40. 
 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 Outpatient Rehabilitation Services.  
 
You have been asked to pay a $40 copayment for 26 physical therapy visits. Physical therapy falls within the 
Outpatient Rehabilitation Services benefit category. The services were provided in an outpatient hospital 
setting. 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 26 physical therapy visits rendered at an in-
network outpatient hospital from June 1, 2021, to July 30, 2021.  
 
Your complaint about potentially being given misinformation is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. The Plan states a response has been 
provided. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous (IV) infusion service (96374) provided on 
February 26, 2021. 
 
You asked the Plan to pay for IV infusion 96374. You say that the Plan has failed to process this claim in 
accordance with applicable standards. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because code 96365 has a procedure-to-procedure (PTP) edit with code 99350 meaning 
that this code is not separately payable without an appropriate modifier. 
 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 code IV 
infusion 96374 is a column II code to column I code 99350. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for intravenous (IV) infusion service (96374) 
provided on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hip orthosis (L1686, L2624) and wrist-hand orthosis 
(L3916) provided on October 8, 2020. 
 
You asked the Plan to pay for a hip orthosis and wrist-hand orthosis. You say that the requested items were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is not covered if the information in the 
patient?s medical record does not adequately support the medical necessity for the item.   
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The provided medical records do not discuss the need for the items at issue. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for a hip orthosis (L1686, L2624) and wrist-hand orthosis (L3916) provided 
on October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hospital bed.
You asked the Plan to pre-approve the hospital bed. You say that you require the hospital bed. The Plan denied your request. The Plan says it could not obtain the necessary information to show that there was medical necessity.
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met: 1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or
3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or 4. The patient requires traction equipment, which can only be attached to a hospital bed. We asked our 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 hospital bed. Our reviewer says that the hospital bed is denied. Our physician reviewer found the documentation does not indicate services are necessary for treatment of the enrollee's condition. We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a hospital bed.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the enrollee needs physical and occupational therapy to be able to go up and down stairs safely in a basement apartment. You state the enrollee is on blood thinners and is at risk for bleeding if they fall. You state the enrollee has a colostomy bag and needs are in a SNF. The Plan denied your request. The Plan says the enrollee can safely receive the services they need in other settings. You state the enrollee's needs can be met from home health at home with supervision or in an assisted living facility. The Plan states the enrollee's need may also be met at a long-term care facility with part-time skilled services.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating household distances and tending to activities of daily living (ADLs) with minimal supervision. The enrollee's care needs, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes; 
massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) (CPT code 
97124), sales tax (CPT code S9999) and manual therapy techniques (eg, mobilization/ manipulation, manual 
lymphatic drainage, manual traction), 1 or more regions, each 15 minutes (CPT code 97140) provided on 
January 28, 2021. 
 You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied 
charges. The Plan denied your request. The Plan says CPT codes billed; 97124, 97140, S9999 do not fall into 
the manual manipulation of the spine to correct subluxation category. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Furthermore, the Plan does 
not make payment for sales taxes. Therefore, we decided that the Plan does not have to pay for therapeutic 
procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement 
(stroking, compression, percussion) (CPT code 97124), sales tax (CPT code S9999) and manual therapy 
techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, 
each 15 minutes (CPT code 97140) provided on January 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the limited bilateral noninvasive 
physiologic studies of upper or lower extremity arteries (93922) provided June 23, 2021. 
 
You asked the Plan to waive the coinsurance for the ultrasound study of arm and leg arteries. You say that this 
is a covered and necessary procedure and should have no cost to you. The Plan denied your request. The Plan 
says the coinsurance has been 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 $150 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physician?s office or at a free-standing facility (such as a radiology center or medical clinic).  
You have been asked to pay $84.59 for the ultrasound study of arm and leg arteries. The ultrasound study of 
arm and leg arteries falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that you have been asked to pay less than or equal to 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 the limited bilateral 
noninvasive physiologic studies of upper or lower extremity arteries (93922) provided June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 30, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that the provider repaired your front right 
tooth in 2020. You went to see the provider again as the tooth had little chips that were coming off and you 
were hoping to get the tooth filled in. The Plan denied your request. The Plan says this service is not covered 
by the member's Plan. 
 
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) provided on June 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional non-emergency routine 
transportation trips. 
 
You asked the Plan to provide coverage for additional non-emergency routine transportation trips. You say that 
the patient does not have transportation or relatives who can take her to her medical appointments. You say it is 
important for her to go to these medical appointments with specialists to prevent complications with her health 
or hospitalizations. The Plan denied your request. The Plan says the evidence shows the enrollee has used all 
twenty-four (24) one-way trips covered by the health Plan for the year 2021. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that the enrollee has used 
all twenty-four (24) one-way transportation trips for the year 2021. Based on this information, we decided that 
the enrollee has exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide coverage for additional non-emergency routine transportation 
trips.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the dermatology services and the injectable 
medication you received on February 12, 2021. 
 
You asked the Plan to waive the deductible for the dermatology services and the injectable medication. You 
say that this was medically necessary and urgent MOHS surgery, and it should be covered. The Plan denied 
your request. The Plan says that you had not met your deductible at the time of these services, so the first $590 
of this bill was charged to you.  Once that was satisfied, you were charged 20% coinsurance for the injectable 
drug. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees have a $590 deductible. However, this deductible does not apply to 
in-network specialist services or in-network Medicare Part B drugs. 
 
According to the case file that the Plan sent to us, the dermatologist who provided these services and the 
injectable drug is a network provider with the Plan.  The Evidence of Coverage explicitly states that the 
deductible does not apply to in-network specialist services or in-network Medicare Part B drugs.  So, it was not 
appropriate for the Plan to assess this deductible in this case. Therefore, we decided that the Plan has to waive 
the deductible for the dermatology services and the injectable medication you received on February 12, 2021.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable neurostimulator for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not have clinical notes that show a significant therapeutic benefit within a 
trial period of one month. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there was no significant clinical benefit from the trial stimulator. There must be a significant benefit 
from the trial device to proceed with implantation. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable neurostimulator for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 8, 2021. 
 
You asked the Plan to pay for ambulance services. You say that you displayed seizure like behavior and fell off 
the bed and the ambulance was called to your home. You say you refused transport to the hospital because you 
had not been vaccinated and had concerns due to Coronavirus. The Plan denied your request. The Plan says 
your Plan covers ambulance transportation only when you are actually transported by ambulance. Since you 
were not transported by this ambulance, the service is not covered. 
 
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 March 8, 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 ambulance services provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CPAP device (E0601) provided on June 17, 2021. 
 
You asked the Plan to pay for a CPAP device. You say that you needed a CPAP device immediately and only 
had one source. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say provide only for rental of CPAP devices and 
accessories. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device have not been met. Specifically, you have purchased rather than renting the item at 
issue. Therefore, we decided that the Plan does not have to pay for a CPAP device (E0601) provided on June 
17, 2021.