Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hand finger orthosis (L3930) and a neuromuscular 
stimulator (E0745) provided on February 26, 2020. 
 
You asked the Plan to pay for a hand finger orthosis and a neuromuscular stimulator. You say that this should 
be covered. The Plan denied your request. The Plan says there was not a face-to-face examination documented 
for these items. 
 
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 Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (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 noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a hand finger orthosis 
(L3930) and a neuromuscular stimulator (E0745) provided on February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 29826). 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 29826 is "Arthroscopy, shoulder, surgical; 
decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) 
release, when performed (List separately in addition to code for primary procedure)". 
 
We asked our coding 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 pay for the services. Our reviewer says that the use 
of CPT code 29826 is not supported by the records provided. Our coding reviewer found that the operative 
report did not include documentation of "acromioplasty (shaving away part of the shoulder bone, called the 
acromion)", therefore, this procedure cannot be verified. 
 
We looked at this coder?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 pay for the services (CPT 29826).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 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 medical services provided to the enrollee by an out-of-network provider 
on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prosthesis preparation services (21080, 21084, 21081) 
provided on January 6, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON prosthesis preparation services. You say that this was medically necessary. 
The Plan denied your request. The Plan says this was not authorized. 
 
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 prosthesis preparation services (21080, 21084, 
21081) provided on January 6, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 21, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you were having severe stomach 
pains so the colonoscopy was recommended. 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 $300 
copayment for surgery services provided in an ambulatory surgical center. 
 
You received a colonoscopy on May 21, 2020, due to severe stomach pains. Therefore, the colonoscopy is 
considered diagnostic, not preventative, and you are responsible to pay the $300 copayment.   
 
You have been asked to pay a $300 copayment for a colonoscopy. A colonoscopy 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 the copayment for a colonoscopy provided on May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) provided on May 27, 2020. 
 
You asked the Plan to pay for the dental service. You say that the procedure you had done included a crown. 
You say that crowns have always been covered. You say that you have no clue what core build up is. You also 
say that the underlying issue was a cavity. The Plan denied your request. The Plan says core build up is not 
listed as covered service. 
 
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, core build up is not among those 
covered under this benefit. The record shows that you received core build up and an extraction on the date of 
service. Additionally, the record shows that the extraction was covered by the Plan. Therefore, we decided that 
the Plan does not have to pay for the core buildup (D2950) provided on May 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI. 
 
You asked the Plan to waive the copayment for an MRI. You say that you were informed that you would owe 
out-of-network charges and request that this is honored. 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 $250 
copayment for in-network advanced imaging services and 50% coinsurance for out-of-network advanced 
imaging services.  
 
The record shows that you received an MRI, from an in-network provider. Therefore, you 
are responsible to pay the $250 copayment.  
 
You have been asked to pay a $250 copayment for an MRI. An MRI 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 copayment for 
an MRI.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite on tooth #29 provided on 
December 5, 2019. 
 
You asked the Plan to pay for the resin-based composite. You say that you thought your insurance would cover 
this service. You also say that you cannot afford to pay for this bill. The Plan denied your request. The Plan 
says this service 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the contract clearly states that your 
benefit includes amalgam (silver) fillings and anterior (front teeth) white fillings. Resin-based composites on 
posterior teeth are not a covered benefit. Tooth #29 is a posterior tooth, and your plan only covers amalgam 
fillings for posterior teeth. Therefore, we decided that the Plan does not have to pay for the resin-based 
composite on tooth #29 provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the orthopedist visit, the x-ray, the knee 
immobilizer, and the Medicare Part B drug injection you received on May 19, 2020. 
 
You asked the Plan to waive the cost sharing for the orthopedist visit, x-ray, knee immobilizer, and injection. 
You say that even though you took out a more expensive medical policy, you are still left with large 
copayments. The Plan denied your request. The Plan says you were charged these amounts 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 $10 
copayment for specialist visits, 10% coinsurance for x-rays, 20% coinsurance for prosthetic devices, and 20% 
coinsurance for Part B drugs. 
 
You have been asked to pay a $10 for the orthopedist visit, 10% coinsurance for the x-ray, 20% coinsurance for 
the knee immobilizer, and 20% coinsurance for the injection. 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 sharing 
for the orthopedist visit, the x-ray, the knee immobilizer, and the Medicare Part B drug injection you received 
on May 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom abutment (D6057) and the abutment supported 
porcelain ceramic crown (D6058) provided on June 3, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are not requesting an implant or that the 
abutment be covered. You say that the denial of implant services does not make sense. You also say that the 
replacement of your broken crown should be covered. The Plan denied your request. The Plan says abutments 
and implant related 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 dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
custom abutment (D6057) and the abutment supported porcelain ceramic crown (D6058) provided on June 3, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on February 17, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 71046. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 71046. Code 71045 is supported as separate and distinct 
from 71046 based on the records; however, code 71045 was not billed with the appropriate modifier to allow 
for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on 
February 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PET from the skull to thigh (78815) provided on January 25, 
2020. 
 
You asked the Plan to pay for the PET. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says C34.90 is not listed as an appropriate diagnosis for this 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PET have not been met. Per CMS' list of appropriate diagnosis codes for this service, C34.90 is 
not an appropriate code. Therefore, we decided that the Plan does not have to pay for PET from the skull to 
thigh (78815) provided on January 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on February 17, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 lab testing provided on February 17, 2020 by an 
out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 22, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 
laboratory services. 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 laboratory services provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided January 16, 2020. 
 
You asked the Plan to pay for the outpatient office visit. You say that this claim is not a duplicate. Please 
reconsider and expedite payment. The Plan denied your request. The Plan says there is an exact duplicate 
claim, which was billed for the same date of service and reprocessed on January 26, 2020. 
 
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, based on the documentation provided, this claim was processed and applied to the enrollee's 
deductible per check dated 01/27/2020. Based on this information, we decided that Medicare rules for coverage 
of the outpatient office visit have not been met. Therefore, we decided that the Plan does not have to pay for the 
outpatient office visit provided January 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 5, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the medics were following the COVID 
executive order for treatment in place. 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 April 5, 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 on April 5, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan provided on April 29, 2020. 
 
You asked the Plan to waive the copayment for a duplex scan. You say that the claims should have been 
processed as in-network. 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 $155 
copayment for each radiological diagnostic service.  
 
You have been asked to pay a $155 copayment for a duplex scan. A duplex scan falls within the outpatient 
diagnostic tests and therapeutic service 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 a duplex scan provided on April 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on November 25, 2019. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says hearing 
aids are not a covered benefit under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to reimburse you for hearing 
aids provided on November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on May 11, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on May 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services (CPT 77412) provided to the enrollee on 
April 14, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code is invalid for Medicare purposes. 
 
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 77412 is "Radiation treatment delivery, more than 1 
MeV." 
 
We find that CPT code 77412 is not supported in the medical record. Specifically, this code has a status 
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for 
Medicare purposes. 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 pay for hospital services (CPT 77412) 
provided to the enrollee on April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the lens upgrades provided on May 14, 2020. 
 
You asked the Plan to reimburse you for the lens tint (V2744), lens anti-reflective coating (V2750), and 
miscellaneous vision item (V2784). You say that the Plan should reimburse you for the covered eyeglasses. 
The Plan denied your request. The Plan says upgrades are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to reimburse you for are considered routine vision services or eyewear. 
Upgrades are not a covered benefit. Therefore, we decided that the Plan does not have to reimburse you for the 
lens upgrades provided on May 14, 2020.