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

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
(95941) provided on December 22, 2021. 
 
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring. You say that the services 
at issue 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
We find that CPT code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of continuous intraoperative neurophysiology monitoring have not been met. Therefore, we decided 
that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (95941) provided 
on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments (D6056) and implant 
supported crowns (D6065), provided by a participating provider. 
 
You asked the Plan to pre-approve custom fabricated abutments and implant supported crowns. You say that 
you cannot eat or bite your food. You say that you are in a lot of pain. The Plan denied your request. The Plan 
says the requested 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
custom fabricated abutments (D6056) and implant supported crowns (D6065), provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a repair of hammertoe (28285) provided on March 16, 2021. 
 
You asked the Plan to pay for a repair of hammertoe. You say that you have provided records to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been met because the 
services at issue are included in the global package of a prior procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not allow separate payment for an 
additional procedure(s) with a global surgery fee period if furnished during the postoperative period of a prior 
procedure and if billed without modifier -58, -78, or -79.  
 
We looked at the file and Medicare rules. In this case, the record shows that the service at issue was provided 
during the postoperative period of a prior procedure. The service at issue was billed without an appropriate 
modifier. Based on this information, we decided that Medicare rules for coverage of a repair of hammertoe 
have not been met. Therefore, we decided that the Plan does not have to pay for a repair of hammertoe (28285) 
provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the primary closure of a sinus perforation on tooth #2 
(D7261). 
 
You asked the Plan to pre-approve a perforation closure. You say that you are suffering with intense pain due 
to this bad tooth. The Plan denied your request. The Plan says primary closure of a sinus perforation (D7261) is 
not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pre-approve the 
primary closure of a sinus perforation on tooth #2 (D7261).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve abutment supported crowns (D6063) provided by a 
participating provider. 
 
You asked the Plan to pre-approve abutment supported crowns. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the requested 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 Plans 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 pre-approve 
abutment supported crowns (D6063) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment (D6056) and implant 
supported crowns (D6065), provided by a participating provider. 
 
You asked the Plan to pre-approve custom fabricated abutment and implant supported crowns. You say that 
you have no teeth, and you cannot eat like this. The Plan denied your request. The Plan says the requested 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
custom fabricated abutment (D6056) and implant supported crowns (D6065), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) and endosteal 
implants (D6010), provided by a participating provider. 
 
You asked the Plan to pre-approve a bone replacement graft and endosteal implants. You say that the implants 
are causing you immense pain. The Plan denied your request. The Plan says the requested 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 Plans 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 pre-approve a 
bone replacement graft (D7953) and endosteal implants (D6010), provided by a participating provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Botox 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 that the safety and effectiveness for Botox for the treatment of trigeminal neuralgia has 
not been established in published medical literature. 
 
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 the services. Our reviewer says that the 
requested Botox is medically reasonable and necessary. Our physician reviewer found based on the medical 
records provided and the Medicare-approved major drug compendia there is documentation that supports that 
the Botox is medically reasonable and necessary for the patient. Micromedex/Drugdex reports a weak 
recommendation for the addition of botulinum toxin type A to other medications for medium-term treatment of 
trigeminal neuralgia (though this is based on very low quality evidence). Under Medicare rules any positive 
citation in the Medicare-approved compendia is adequate for designation of a medically accepted indication. 
The class of the evidence in the citation is not controlling in these cases. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve Botox for the enrollee.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this claim should be 
paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) and the 
mechanical traction therapy (97012) rendered by the out-of-network (OON) provider from March 10, 2021, 
through April 5, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the chiropractic manipulative treatment (98940) and the mechanical traction 
therapy (97012) rendered by the out-of-network (OON) provider from March 10, 2021, through April 5, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the services were 
provided out-of-network 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 the office visit provided on February 3, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on October 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast surgery (augmentation with implant, mastopexy) 
and other procedures (abdominoplasty, thigh lift) 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of the need for abdominal lipectomy or panniculectomy due 
to evidence of a chronic infection or inflammation that is refractory to treatment and there is no documentation 
of the need for breast reconstruction following a medically necessary mastectomy. 
 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 that the record indicates that the enrollee has had massive weight loss. The record provided is 
insufficient to establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. The elements of the coverage criteria are not satisfied. 
 
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 breast surgery (augmentation with implant, mastopexy) and other procedures 
(abdominoplasty, thigh lift)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on 
February 20, 2022, to February 25, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you wanted to leave two 
days earlier but were made to stay so that charge should be covered. The Plan denied your request. The Plan 
says the copayment applied is correct. 
 
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 $345 
copayment per day (per Medicare-covered stay), which includes day of admission and day of discharge. 
 
 
 
 
 You have been asked to pay $1,725($345 x 5 days) copayment for inpatient hospital stay. Inpatient hospital 
stay falls within the Inpatient hospital 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 inpatient hospital stay provided on February 20, 2022, to February 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayments for abdominal peritoneocentesis 
procedures performed from January 13, 2022, to February 23, 2022. 
 
You asked the Plan to waive or reduce the copayments for the abdominal peritoneocentesis. You say that the 
copayments are steep and you will need this procedure 4 times per month for the foreseeable future. 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 $100 
copayment per day for outpatient procedures and services.  
 
You have been asked to pay a $100 copayment for each of the 4 the abdominal peritoneocentesis procedures, 
for a total of $400. The abdominal peritoneocentesis falls within the Outpatient Surgery, Including Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive or reduce the copayments for abdominal peritoneocentesis procedures performed from 
January 13, 2022, to February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on February 
22, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that you do not know which lab 
services are covered and which ones are not. 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 $0 
copayment for routine lab services and a $10 copayment for all others.  
 
The file shows that the lab service provided for creatine kinase levels is not routine. Therefore, you have been 
asked to pay $6.51, which is less than the $10 copayment for the lab services. The lab services fall 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 laboratory services provided on February 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a comprehensive electrophysiologic 
evaluation provided from November 22, 2021, to November 24, 2021. 
 
You asked the Plan to waive the coinsurance for the comprehensive electrophysiologic evaluation. The Plan 
denied your request. The Plan says the correct coinsurance was 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 a 20% 
coinsurance for diagnostic tests.  
 
You have been asked to pay $3,517.70, which is less than the 20% coinsurance for the comprehensive 
electrophysiologic evaluation ($18,847.47 allowed amount x 20% = $3,769.49). The comprehensive 
electrophysiologic evaluation 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 coinsurance for a comprehensive 
electrophysiologic evaluation provided from November 22, 2021, to November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exercise classes (S9451) provided on January 15, 2022, 
and February 3, 2022. 
 
You asked the Plan to pay for the exercise classes. You say that you thought the gym membership would be 
covered by the Plan's fitness program benefit. The Plan denied your request. The Plan says you did not contact 
the Plan prior to the dates of service to obtain the confirmation code needed for the Plan's fitness program 
benefit, as outlined in the Enrollment Requirements found in your 2022 Evidence of Coverage. The Plan also 
says that while there are select fitness facilities that are included in the Plan's network, the facility you went to 
is not one of those. 
 
  The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when you enroll in the Program according to the Plan's instructions. 
 
The Plans rules for coverage of gym benefits have not been met because you did not attend an in-network 
facility, and you did not contact the Plan prior to these dates of service to obtain the confirmation code that was 
needed to enroll in the Plan's fitness program benefit. Therefore, we decided that the Plan does not have to pay 
for the exercise classes (S9451) provided on January 15, 2022, and February 3, 2022.