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

 
We decided that the Plan does not have to pay for the complete maxillary denture provided on July 27, 2020. 
 
You asked the Plan to pay for the complete maxillary denture. You say that your 2020 EOC does not say 
anything about both dentures needing to be completed on the same day. The Plan denied your request. The Plan 
says benefits for this service have been satisfied and the frequency limitation has been exceeded. 
 
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, you are limited to one upper complete 
and/or one lower complete denture every five years. The record shows that you received a complete maxillary 
denture on January 6, 2019, and your complete maxillary denture benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the complete maxillary denture provided on July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx-Melanoma testing provided on July 20, 
2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that NCCN Guidelines, Version 1.2021, state that it remains unclear whether gene expression profiling 
provides clinically actionable prognostic information when used in addition to or in comparison with known 
clinicopathologic factors of multivariable nomograms that incorporate patient sex, age, tumor location and 
thickness, ulceration, lymphovascular invasion, micorsatellites, and SLNB status. "Furthermore, the impact of 
these tests on treatment outcomes or follow-up schedules has not been established." 
 
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 testing have not been met. Please note that the LCD referenced by the Plan 
was not used as it is not applicable for the jurisdiction in question. Therefore, we decided that the Plan does not 
have to pay for the DecisionDx-Melanoma testing provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye examination provided on September 
29, 2020. 
 
You asked the Plan to waive the copayment the eye examination. You say that you had identical visits in July 
and April, and you did not have a $15 copayment. The Plan denied your request. The Plan says a diagnostic eye 
exam was rendered on September 29, 2020, which required a $15 copayment. 
 
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 $15 
copayment for vision care, Medicare-covered eye exam to diagnose and/or treat a disease or condition of the 
eye. 
 
You have been asked to pay $15 copayment for the eye examination. The eye examination falls within the 
vison 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 an eye examination 
provided on September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 1, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for urinary catheters. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for these supplies is correct, because this 
provider is out-of-network with the Plan and authorization was not obtained. 
 
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 medical services provided on June 1, 2020 by 
an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by THE Volunteer 
Ambulance on September 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were trying to avoid the costly tests 
from the emergency room since the pain had gone following the medics arrival. 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 September 19, 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 
Volunteer Ambulance on September 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded 
14001 provided on October 14, 2019. 
 
You asked the Plan to pay for the adjacent tissue transfer or rearrangement services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
supported by the documentation. 
 
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 14001 is adjacent tissue transfer or rearrangement, trunk; 
defect 10.1 sq cm to 30.0 sq cm. 
 
We find that CPT code 14001 is not supported in the medical record. Specifically, the documentation submitted 
indicate that adjacent tissue transfer or rearrangement, trunk; defect was performed; however do not indicate 
the size of the defect; therefore, the billed service cannot be verified. Based on this information, we decided 
that Medicare rules for coverage of the adjacent tissue transfer or rearrangement services have not been met. 
Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement 
services coded 14001 provided on October 14, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography services coded 95867 provided 
on July 1, 2020. 
 
You asked the Plan to pay for the needle electromyography services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and the appropriate diagnosis codes. 
 
In this case, the CPT Code Manual definition of code 95867 is needle electromyography; cranial nerve supplied 
muscle(s), unilateral. 
 
Review of the file shows that code 95867 was billed with diagnosis code I65.21. Diagnosis code I65.21 is not 
listed in the ICD-10 Codes that Support Medical Necessity section of the LCA. Based on this information, we 
decided that Medicare rules for coverage of the needle electromyography services have not been met. 
Therefore, we decided that the Plan does not have to pay for the needle electromyography services coded 
95867 provided on July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided form 
June 20, 2020, to July 20, 2020. 
 
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you 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 20% 
coinsurance for DME and related supplies.  
 
You received DME and related supplies from June 20, 2020, to July 20, 2020. The allowed amount is $74.88 
and 20% of that is $14.98.  
 
You have been asked to pay the total coinsurance amount of $14.98 for DME and related supplies. DME and 
related supplies fall within the DME and related 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 DME and related supplies provided form June 20, 2020, to July 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that the enrollee can be treated in a lower 
level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the 
enrollee. The enrollee can be treated in a lesser restrictive setting as he is not showing any suicidal or homicidal 
ideation, auditory or visual hallucinations and is not showing any abnormal behaviors while being cooperative 
and compliant. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
inpatient psychiatric hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays provided. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you have been paying out of 
pocket for the denied dental claims, and would like this claim to be reprocessed and paid because this is what 
you pay insurance for. The Plan denied your request. The Plan says this service is 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 pay for the 
complete series of intraoral x-rays provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the routine dental services provided from July 8, 
2020, to July 15, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that your tooth had an abscess. You say 
that you were prescribed an antibiotic and referred to another dentist. You say that from there you were referred 
to another dentist to perform an extraction, bone graft, and implant due to the tooth being fractured and non-
salvageable. You say that you are aware that your plan does not normally cover dental services. You also say 
that you would like the services to be covered as a one-time exception due to the impact an infection could 
have on your overall health. The Plan denied your request. The Plan says the services you received were dental 
in nature. The Plan says that routine dental services are not covered. The Plan says that the providers you saw 
on July 8, 2020 are out of network. The Plan says that the provider that you saw on July 9, 2020, and July 15, 
2020 has opted out of Medicare. The Plan also says that payment cannot be made for services that you receive 
from a provider who has opted out of Medicare. 
 
 
Medicare generally does not cover dental services. The Plan follows the same rule. The rules also say that no 
Medicare payment may be made to a beneficiary for items or services provided directly by a physician or 
practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 
 
The services you received on July 8, 2020 that you are asking the Plan to reimburse you for involve the care, 
treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These 
are dental services that are not covered or paid for by Medicare. Additionally, the services at issue from July 9, 
2020, to July 15, 2020 were provided in a non-urgent, non-emergent situation by the provider who has opted 
out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the 
routine dental services provided from July 8, 2020, to July 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic mammogram rendered on August 31, 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 services are not covered. 
 
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 77065 is 1. You billed 2 units of this code, exceeding the MUE. 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 diagnostic mammogram rendered on August 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on October 15, 2019. 
 
You asked the Plan to pay for genetic testing. You say that Medicare no longer considers this testing to be 
experimental/investigational. The Plan denied your request. The Plan says the denial of payment for this testing 
is correct, because this testing was not approved by the Food & Drug Administration (FDA) and the enrollee 
did not meet criteria for this testing. 
 
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 pay for genetic testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in 2019, the enrollee was being evaluated for asymptomatic microcytosis. Testing specifically 
related to the microcytosis for which associated therapies were known, was medically reasonable and 
necessary. Panel testing, including of testing that was not specifically related to microcytosis or for which there 
were no associated therapies, was not medically reasonable and necessary. The documentation does not support 
that the requested panel testing was medically necessary to diagnose, treat, or otherwise manage the enrollee's 
condition. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing provided on October 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services provided from July 17, 2020, 
through August 5, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claims were 
processed accordingly with your 2020 EOC benefits. The rules say a plan must disclose to its enrollees in clear, 
accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the 
file show that you received specialist office services provided on July 17, 2020. You are asked to pay a $30 
copayment for the services. Furthermore, you received diagnostic testing services on August 5, 2020, provided 
by the outpatient department of the hospital. You are asked to pay a $25 copayment for the testing. Your EOC 
states, enrollees must pay a $25 copayment for each Medicare-covered X-ray service in other facilities (e.g., 
ambulatory surgical center or outpatient hospital) and a $30 copayment for services obtained from a specialist. 
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 services provided from July 17, 2020, through August 5, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for infectious agent detection by nucleic acid 
(DNA or RNA); Streptococcus, group B, amplified probe technique (CPT Code 87653) provided on July 7, 
2020. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you are being charged a 
copayment for a COVID 19-test. The Plan denied your request. The Plan says the copayment processed 
correctly for the strep test, the COVID-19 test processed with no copayment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The $15 laboratory copayment applied correctly to the billed strep 
test as this is not a covered COVID-19 CPT code. 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 
infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 
(CPT Code 87653) provided on July 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on July 29, 
2020. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you have never received a 
copayment for any services done through primary care physician. The Plan denied your request. The Plan says 
the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received laboratory services on July 29, 2020. You were asked to pay a $15 
copayment for the laboratory services. Your EOC states that enrollees must pay a $15 copay per visit for 
laboratory tests, non-radiological diagnostic tests, flat film X-rays, and ultrasounds. 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 July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from July 1, 2020, 
through July 8, 2020, by an in-network provider. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you do not believe you owe the full 
amount. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 
EOC benefits. 
 
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 EOC clearly states that you are responsible for a $0 copayment per day, days 1-20 and $178 copayment 
per day, days 21-100. A benefit period begins the day you go into a hospital or skilled nursing facility. The 
benefit period ends when you have not received any inpatient hospital care, or skilled care in a SNF, for 60 
days in a row. This was a continued SNF stay, as you had already been at the facility for dates of service June 
10, 2020, through June 30, 2020, a total of 20 days. 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 
SNF care provided from July 1, 2020, through July 8, 2020, by an in-network provider.