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

We decided that the Plan does not have to pay for the dental services received on August 24, 2020. 
 
You asked the Plan to pay for the dental services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received are 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 Plan's coverage rules apply in this case. The Plan covers the dental 
services when provided by a participating provider.  
 
We looked at the file and Medicare rules. Your contract with the plan shows that dental services are only 
covered when received by a participating provider. Review of the file shows that you received these dental 
services from a non-participating provider. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
the dental services received on August 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on January 7, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says Medicare 
pays for a limited number of services via a telecommunications system. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a MSA or a rural HPSA located in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are 
likewise non-covered. Therefore, we decided that the Plan does not have to pay for the lab testing services 
provided on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network dentist on 
March 4, 2020. 
 
You asked the Plan to pay for dental services. You say that there is nothing you have been able to find within 
the Plan benefits that would explain why this was not paid. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because this provider is out-of-network and your primary 
insurance carrier already paid more than the maximum allowable amount for these services; therefore, there is 
no remaining allowable amount for the Plan to pay on this claim. 
 
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 dental 
services with payment based on contracted rates for each covered service and excludes payment for services 
performed by an out-of-network dentist. 
 
We looked at the file, the Plan?s rules, and Medicare?s rules. This dentist is out-of-network with the Plan. 
Furthermore, your primary insurance carrier already paid more than the contracted rate for these dental 
services. Therefore, the Plan is not required to make additional payment for this claim. Based on this 
 
 
information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we 
decided that the Plan does not have to pay for dental services provided by an out-of-network dentist on March 
4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the radiation therapy services and 
radiosurgery provided March 27, 2018, to June 21, 2018. 
 
You asked the Plan to waive the cost share for the radiation services and radiosurgery. You say that you want 
to verify you are paying the correct cost share and were unaware you are utilizing the services of an out-of-
network provider. The Plan denied your request. The Plan says the cost share applied correctly in this case. 
 
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% 
coinsurance for OON radiation therapy services and a $70 copayment for OON specialist services.  
 
You have been asked to pay a total cost share amount of $618.30. The plan mistakenly charged you the 20% 
coinsurance rate for March 27, 2018, and March 28, 2018 ($6.13 and $13.60). They will not be attempting to 
correct this claim and are leaving the 20% coinsurance as is. They then charged you 40% OON coinsurance for 
June 11, 2018, to June 21, 2018 ($49.23, $136.32, $107.08, $31.94, $95.20, $108.80). Finally, they charged the 
$70 copayment for specialty services. Altogether, these equal your total cost share of $618.30. 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 cost share for the radiation therapy services and radiosurgery provided March 27, 
2018, to June 21, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health speech services, each 15 minutes (G0153) 
provided on March 16, 2020 to March 29, 2020. 
 
You asked the Plan to pay for the home health services. You say that this claim was processed with out of 
network benefits. This claim was not processed under the correct policy. Please review and reprocess this claim 
with in network benefits. The Plan denied your request. The Plan says resubmit claim with the correct bill type. 
 
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 G0153 is services performed by a qualified speech-
language pathologist in the home health or hospice setting, each 15 minutes. 
 
We find that CPT code G0153 is not supported in the medical record. Specifically, the claim was billed with an 
invalid type of bill for a non-participating home health provider. Based on this information, we decided that 
Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health speech services, each 15 minutes (G0153) provided on March 16, 2020 to 
March 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services (G0463) 
provided on August 17, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital service. You say that you should not be 
charged a copay. The Plan denied your request. The Plan says the copay 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 a $20 
copayment for outpatient hospital services.  
 
You have been asked to pay a $20 copayment for outpatient hospital service. This service falls within the 
outpatient hospital 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 
hospital services (G0463) provided on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and the additional 
periapical x-ray (D0230) provided on August 13, 2020. 
 
You asked the Plan to pay for the dental services. You say that this was a normal routine dentist visit. You say 
that you would not have gotten the x-rays if you had known they would not be covered. You say that you 
cannot afford to pay for these services. The Plan denied your request. The Plan says periapical x-rays are not 
listed as covered 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. 
 
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 initial 
periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation provided on August 27, 
2020. 
 
You asked the Plan to pay for comprehensive oral evaluation. You say that you had no other provider to go to 
during the COVID-19 pandemic. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because this procedure is covered once every 3 plan-years and you previously received a 
comprehensive oral evaluation (D0150) on December 4, 2018. 
 
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. The Plan covers 
comprehensive oral evaluation once every three plan-years.  
 
We looked at the file, the Plans rules, and Medicare rules. You previously had a comprehensive oral 
evaluation on December 4, 2018 which was less than 3 plan-years prior to this exam. Based on this 
information, we decided that the Plan's rules for coverage of comprehensive oral evaluation have not been met. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation provided on 
August 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on May 6, 2020 and billed under code 81479.You asked the Plan to pay forthis service. You say that this testing was medically necessary and should be covered by the Plan.The Plan denied your request. The Plan says the records provided do not show there was a concern for transplantrejection at the time of service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare has specific coverage criteria for this type of testing. In this case, the records provided do not show the enrollee met all the criteria stated above at the time of service. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forlab services provided to the enrollee on May 6, 2020 and billed under code 81479
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the safest and most 
efficient care level based on the enrollee's current conditions and needs and that the enrollee has failed at a 
lower level of care. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that LTACHs are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee 
is receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where he is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special lens inserted during cataract surgery. 
 
You asked the Plan to pre-approve special lens inserted during cataract surgery. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the premium IOL 
and a conventional IOL.  
 
While a premium IOL may be appropriate for you, neither the Plan nor Medicare covers the premium feature of 
an IOL. Therefore, we decided that the Plan does not have to pre-approve special lens inserted during cataract 
surgery.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the emergency room services provided on 
December 13, 2019. 
 
You asked the Plan to waive the copay for the services provided. You say that the copay should be waived due 
to the pandemic. The Plan denied your request. The Plan says the cost share was 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 $90 
copay for each emergency room visit.  
 
You have been asked to pay a $90 copay for the services provided. The services fall within the emergency care 
benefit category. The documentation shows that copays for certain services will be $0 between May 11, 2020, 
until September 30, 2020. The services at issue in this appeal was provided prior to the Plan?s copay waiver. 
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 copay for the emergency room services provided on December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 30, 
2019. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you have not been charged in the 
past and disagree with 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 $45 
copayment for specialist services.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug tests (G0483 and 80307) provided on June 30, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for drug tests. You say that you provided medically necessary services in good faith. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 has network providers 
available who can provide 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 drug tests (G0483 and 80307) provided on 
June 30, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided on March 13, 2020 
billed with a second unit of code 57282-AS. 
 
You asked the Plan to pay for the surgical assistant services. You say that these services were medically 
necessary and should be paid. The Plan denied your request. The Plan says one unit of code 57262 was 
approved for payment. There is no evidence that services representing a second unit were provided. As such, 
the second unit remains denied. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 57282-AS is 1. You billed two units of this code on two line items, 
exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the surgical 
assistant services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical 
assistant services provided on March 13, 2020 billed with a second unit of code 57282-AS.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic custom molded shoe and the multiple density 
insert provided on June 16, 2020. 
 
You asked the Plan to pay for the diabetic custom molded shoe and the multiple density insert. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says a valid proof of 
delivery was not provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file 
shows that the proof of delivery submitted with the claim is not itemized to indicate the specific supplies. 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 the diabetic custom molded shoe and the multiple 
density insert provided on June 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on November 25, 2019. 
 
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require 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 
home visit. 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 a home visit provided on November 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by THE County 
Fire Protection District on May 20, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 May 20, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by THE 
County Fire Protection District on May 20, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room care provided on May 
26, 2020. 
 
You asked the Plan to waive the copayment for the emergency room care. You say that you feel the copayment 
should be waived as you were sent home. The Plan denied your request. The Plan says the copayment applied 
correctly in this case. 
 
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 $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for the emergency room care. The service provided falls within 
the emergency 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 the emergency room 
care provided on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0364, D0140, D1999) received on May 14, 
2020. 
 
You asked the Plan to pay for the services. You say that no one told you about a frequency limitation. The Plan 
denied your request. The Plan says the 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. You previously had an exam billed as D0140 on March 17, 2020. This 
is only covered once per year. The other two codes - D0364 and D1999 - are not listed as being covered in your 
plan contract, even though the plan did write off the charge for D1999. Therefore, we decided that the Plan 
does not have to pay for dental services (D0364, D0140, D1999) received on May 14, 2020.