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

 
We decided that the Plan does not have to reduce the deductible for the chiropractic services provided on July 
20, 2023. 
 
You asked the Plan to reduce the deductible for the chiropractic services. You say that you had been charged 
incorrectly. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 there is a $300 deductible which applies to chiropractic services.  
 
 
 
 
 You have been asked to pay $36.05 towards the $300 deductible for the chiropractic services. The item or 
service you asked the Plan to reduce the deductible for falls within the chiropractic services benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which 
applies to chiropractic services. This cost sharing is a contractual obligation that had not been met at the time 
the chiropractic services was received on July 20, 2023. Therefore, we decided that the Plan does not have to 
reduce the deductible for the chiropractic services provided on July 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for a specialist office visit provided on June 
30, 2023. 
 
You asked the Plan to reduce the deductible for a specialist office visit. You say that this visit should be 
covered under the colonoscopy procedure. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 there is a $400 deductible which applies to physician/practitioner services, 
including doctors office visits.  
 
 
 You have been asked to pay $110.30 towards your $400 deductible. The item or service you asked the Plan to 
reduce the deductible for falls within the physician/practitioner services, including doctors office visits benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 
deductible which applies to physician/practitioner services, including doctors office visits. This cost sharing is 
a contractual obligation that had not been met at the time a specialist office visit was received on June 30, 
2023. Therefore, we decided that the Plan does not have to reduce the deductible for a specialist office visit 
provided on June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483) provided on May 30, 2023. 
 
You asked the Plan to pay for procedure code G0483. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say while a physician order is not required to be signed, 
the physician must clearly document, in the medical record, the intent that the test be performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, medical records submitted 
do not include an order that specifically list what test(s) are to be performed in the custom panel. Based on this 
information, we decided that Medicare rules for coverage of procedure code G0483 have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug testing (G0483) provided on May 30, 
2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided 
on June 08, 2023. 
 
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree 
with the copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for outpatient rehabilitation services. This item/service falls 
within the outpatient rehabilitation 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 outpatient rehabilitation services provided on June 08, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on August 10, 
2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as they 
were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids purchased on August 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar spinal fusion at L5-S1 (20930, 22852, 22830, 
22840). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this enrollee was being treated for low back pain. He presented with low back pain that has 
worsened since the last office visit. There is bilateral lower extremity pain all the way to the toes. The pain is 
rated at 5/10. The exam reveals asymmetry and a scar is present from a prior surgery.   
 
There is no evidence of muscle atrophy. The straight leg raise test is negative. However, detailed 
documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative 
care measures is not evident. Moreover, dynamic flexion/extension films are not provided in order to 
potentially assess the amount of movement (instability) at the requested surgical level. Detailed documentation 
is not evident regarding potential impending/inevitable temporary intra-operative instability. There are limited 
large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical 
setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested lumbar spine fusion at L5-S1 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar spinal fusion at L5-S1 (20930, 22852, 22830, 22840).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 95822, 95999, and 95861 provided on 
August 15, 2022. 
 
You asked the Plan to pay for procedure codes 95822, 95999, and 95861. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as billed. 
 
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 95822 is electroencephalogram (EEG); recording in coma 
or sleep only. We find that CPT code 95822 is not supported in the medical record. Specifically, the record 
shows that this EEG was provided during surgery, and not during coma or sleep. Based on this information, we 
decided that Medicare rules for coverage of the EEG as billed have not been met. 
 
Additionally, we find that CPT code 95999 is not supported. Code 95999 was used to describe Train of Four 
testing. Train of Four testing is bundled with the intraoperative neuromonitoring and not separately reportable. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. 
 
Lastly, Medicare rules also say that submitted claims in which the unit of service exceeds the MUE value 
cannot be paid when the MAI value is 3, unless there is evidence justifying the excess units. In this case, the 
MUE for CPT code 95861 is 1. The MAI value for this code is 3. You billed 2 units of this code, exceeding the 
MUE. The documentation does not justify the excess units billed. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 95822, 95999, and 
95861 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95822, 
95999, and 95861 provided on August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye examination provided on April 3, 
2023. 
 
You asked the Plan to waive the copayment for the eye examination provided on April 3, 2023. You say that 
you requested only a routine vision exam and was not seeking treatment for any medical conditions of the eye. 
You say that this claim was processed incorrectly and there should be a $0 copayment. The Plan denied your 
request. The Plan says this cost sharing was charged 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 $35 
copayment for each visit to a specialist, such as an ophthalmological or optometrist, for Medicare covered 
benefits.  You have been asked to pay a $35 copayment for the eye examination provided on April 3, 2023. This service 
falls within the vision care benefit category. The medical record shows a diagnosis of cataracts which makes 
the eye examination medical in nature. 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 eye 
examination provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a determination of refractive state on May 11, 2023. 
 
You asked the Plan to reimburse for a determination of refractive state. You say that the provider was not able 
to access the funds on your Plan card because their credit card processing system can only process credit cards. 
You also say because of that, you had to pay the remaining charges with your personal credit card. The Plan 
denied your request. The Plan says this is a non-covered item or service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when it is part of a routine eye examination and from an in-network 
optical provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that eye refractions are only included during a 
routine eye examination. The Plan rules also say any benefits received at a non-network optical provider are 
excluded from this benefit. The Plan rules also say that upon request, you receive a Plan card that can only be 
used at participating providers. The record shows this provider was not a participating provider. Based on this 
information, we decided that the Plan's rules for coverage of a determination of refractive state have not been 
met. Therefore, we decided that the Plan does not have to reimburse for a determination of refractive state on 
May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on June 22, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this procedure was necessary to determine the 
extent of oral surgery needed to remove the tooth. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 22, 2023. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided 
on June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) and core buildup 
(D2950) provided on March 1, 2023. 
 
You asked the Plan to pay for a porcelain/ceramic crown (D2740) and core buildup (D2950). You say that 
according to the Plan's policy, you are covered for any dental service up to $1,500. The Plan denied your 
request. The Plan says there is no coverage for these services. 
 
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. The record shows you have the mandatory supplemental dental 
benefit. Therefore, we decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) and 
core buildup (D2950) provided on March 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (D0364) provided on 
May 19, 2023. 
 
You asked the Plan to pay for a cone beam computed tomography (D0364). You say that you feel the service 
was a medically necessary diagnostic procedure. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
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 pay for a cone 
beam computed tomography (D0364) provided on May 19, 2023.
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 SNF services to regain their prior 
level of functioning and their home is not ideal for rehabilitation. The Plan denied your request. The Plan says 
the request is not medically necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy provided on July 14, 2023, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the medical nutrition therapy. You say that you believe the provider should be 
paid because she had very good guidance regarding her work. The Plan denied your request. The Plan says the 
provider was out-of-network and there was no 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for service. Therefore, we decided 
that the Plan does not have to pay for the medical nutrition therapy provided on July 14, 2023, by an out-of-
network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from December 2, 2022, to 
December 5, 2022. 
 
You asked the Plan to pay for inpatient care. You say that you have submitted documentation to support 
medical necessity for the services rendered. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for inpatient care provided from December 2, 2022, to December 
5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement procedure provided on May 31, 2023. 
 
You asked the Plan to pay for the debridement procedure. You say that you are requesting reconsideration of 
the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the debridement 
procedure provided on May 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for chiropractic manipulative treatment x3 (98941 x2 and 
98942 x1), office visit, x-rays (72040, 72070, 72100, 72170), and manual therapy technique x2 provided by a 
chiropractor on June 23, 2023, to June 29, 2023. 
 
You asked the Plan to pay more for chiropractic services. You say that all the services you received should be 
covered by your insurance. The Plan denied your request. The Plan says this is not a covered chiropractic 
service. 
 
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 services at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay more for the office visit, x-rays (72040, 72070, 72100, 72170), and manual 
therapy technique x2 provided by a chiropractor on June 23, 2023, to June 29, 2023. 
 
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 $10 
specialists office copayment for in-network Medicare covered chiropractic services. 
 
You have been asked to pay a total of $30 for manipulative treatment visits ($10/visit x 3 visits = $30). These 
services fall within the chiropractic 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 pay more for 
chiropractic manipulative treatment x3 (98941 x2 and 98942 x1), provided by a chiropractor on June 23, 2023, 
to June 29, 2023.