Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99328) and the 
comprehensive assessment (G0506) rendered by the out of network (OON) provider on July 25, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan 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 domiciliary or rest home visit (99328) and the comprehensive assessment (G0506) 
rendered by the out of network (OON) provider on July 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic imaging of the optic nerve 
(92133) performed on June 10, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic imaging of the optic nerve. You say that you had a 
normal eye exam. The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for all diagnostic procedures and tests, except X-rays and Medicare-defined preventive procedures 
and tests.  
 
You have been asked to pay a $36.26 copayment for a diagnostic imaging of the optic nerve. A diagnostic 
imaging of the optic nerve falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 
benefit category. This means that you have been asked to less than pay the full 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 diagnostic imaging of the optic 
nerve (92133) performed on June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950) provided on May 13, 2020. 
 
You asked the Plan to pay for the dental service. You say that tooth # 18 already had a crown in place. You say 
that the root canal was not related to the core build up or the crown. You also say that the core build up was not 
required to hold the crown. The Plan denied your request. The Plan says the core build up must be performed 
together with a crown. The Plan also says that a crown was not performed. 
 
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 and core build up is listed as a covered 
service, it is required that it be performed together with a crown. Therefore, we decided that the Plan does not 
have to pay for the core build up (D2950) provided on May 13, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided by a participating 
hospital on February 11, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you are paying for a heart surgery 
at the moment and you cannot afford this. The Plan denied your request. The Plan says the correct copayment 
has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for outpatient surgery/hospital.  
 
You have been asked to pay a $100 copayment for a colonoscopy. A colonoscopy falls within the outpatient 
surgery/hospital 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 by a participating hospital on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the enamel micro-abrasion (D9970) 
provided on June 12, 2020 by the out of network provider. 
 
You asked the Plan to pay the in network rate for the enamel micro-abrasion. You say that your tongue had 
lacerations, ulcerations and swelling. You say that you were advised the services would be covered. You also 
say that the dental office is in network. The Plan denied your request. The Plan says enamel micro-abrasion is 
not listed as a 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, the service you received is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate 
for the enamel micro-abrasion (D9970) provided on June 12, 2020 by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on October 26, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that you had a medical emergency and the 
medics stabilized you. 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 October 26, 2019. 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 October 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided by an out-of-network provider on June 17, 
2020. 
 
You asked the Plan to pay for the services. You say that you were not able to use an in-network facility due to 
the pandemic. The Plan denied your request. The Plan says the services were available in-network. 
 
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 at the 
in-network benefit level rather than the point-of-service benefit level. Therefore, we decided that the Plan does 
not have to pay for surgery provided by an out-of-network provider on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have waive the coinsurance for hearing aids provided on June 15, 2020. 
 
You asked the Plan waive the coinsurance for the hearing aids. You say that you were told the hearing aids 
would be covered with no charge to you and you were misled by the provider. The Plan denied your request. 
The Plan says you are responsible for any money due over $1,000 for hearing aids provided by in-network 
providers. 
 
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 any 
amount over $1,000 for hearing aids provided in-network.  
 
You have been asked to pay the amount over $1,000 for the hearing aids. The hearing aids falls within the 
hearing aids 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 waive the coinsurance for hearing aids provided on 
June 15, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided on September 13, 2019. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to justify 
payment. The Plan denied your request. The Plan says that these claims were denied as duplicates. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.  Specifically, the Plan has provided no evidence of them paying duplicate 
claims.  The case file submitted by the plan contains no additional claims beyond the ones in dispute.  The Plan 
provided no evidence that other claims were paid either to you or any other provider on this date of service.  
There was no substantiating documentation supporting the Plans claim of duplicate other than the Plans own 
case narrative.  The Plan has the obligation to substantiate their denial and we find that they have not done so in 
this case. Therefore, we decided that the Plan has to pay for the lab services provided on September 13, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on August 27, 2019. 
 
You asked the Plan to pay for the outpatient hospital 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 
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 outpatient hospital services provided on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive dental exam. 
 
You asked the Plan to pay for the comprehensive dental exam. You say that you wanted to change dentist and 
needed the exam. The Plan denied your request. The Plan says the exam for a new patient is only covered every 
3 years. 
 
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 
comprehensive dental exam when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the comprehensive dental exam have not been met. You had an exam. 
Therefore, we decided that the Plan does not have to pay for the comprehensive dental exam provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services described by code D1999 provided on 
June 24, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were never told that this would not be 
covered. The Plan denied your request. The Plan says you were not enrolled in the plan's dental rider on this 
date of service. It was decided to allow payment for the x-rays since the provider did not have a treatment plan 
signed. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay 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. Therefore, we decided that the Plan does not have to pay for the dental services described by 
code D1999 provided on June 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the F2 gene analysis provided on March 17, 2020. 
 
You asked the Plan to pay for the F2 gene analysis. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The F2 gene analysis at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
F2 gene analysis provided on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided by a participating 
provider on July 20, 2020. 
 
You asked the Plan to waive the copayment for lab work. You say that you never have had to pay for lab work 
before. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for outpatient diagnostic tests/diagnostic lab services.  
 
You have been asked to pay a $5 copayment for lab work. Lab work falls within the outpatient diagnostic 
tests/diagnostic lab 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 lab work 
provided by a participating provider on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral periapical X-Ray (additional image) provided on 
May 5, 2020. 
 
You asked the Plan to pay for periapical X-Ray. You say that this was the only open dental office in your area. 
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this 
periapical X-Ray exceeded the covered frequency limit for this service. The Plan also says that they have 
reprocessed and approved payment for the other dental services provided, so this denial is only for the 
additional periapical X-Ray performed. 
 
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 one periapical 
X-Ray procedure per calendar year. 
  
We looked at the file, the Plan's rules, and Medicare rules. The Plan approved payment for 1 periapical X-Ray 
performed on this date of service. Therefore, the benefit for periapical X-Rays was exhausted and this 
additional image is not covered by the Plan's dental benefits. Based on this information, we decided that the 
Plan's rules for coverage of periapical X-Ray have not been met. Therefore, we decided that the Plan does not 
have to pay for an intraoral periapical X-Ray (additional image) provided on May 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210) and bone graft for ridge preservation 
(D7953) provided on February 27, 2020. 
 
You asked the Plan to pay for the dental services. You say that the provider advised that your insurance would 
cover the services. The Plan denied your request. The Plan says extraction is not listed as a covered service. 
The Plan says bone graft for ridge preservation is not listed as a covered service either. 
 
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 
extraction (D7210) and bone graft for ridge preservation (D7953) provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit you had with an orthopedist 
on June 19, 2020. 
 
You asked the Plan to waive the copayment for the orthopedic office visit. You say that this was a simple 
follow-up visit that lasted less than five minutes. You said that you shouldn't have to pay a copayment for this. 
The Plan denied your request. The Plan says you were charged this copayment 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 $30 
copayment for specialist office visits.  
 
You have been asked to pay a $30 copayment for the orthopedic office visit. The orthopedic office visit falls 
within the specialist office visits benefit category. This copayment applies regardless of how long the visit 
lasts. 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 office visit you had with an orthopedist on 
June 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test services provided on February 20, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the drug test services. The Plan denied your request. The Plan says the services 
were rendered by a non-network provider. The Plan also says that the enrollee was referred by another non-
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 test services provided on February 20, 
2020 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on April 24, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you weren't told that this was not in-
network. You say that you assumed the specialist would refer you to an in-network provider. The Plan denied 
your request. The Plan says the copayment 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 $125 
copayment for CT scans performed by a provider other than your primary care physician.  
 
You have been asked to pay $115.08, which is less than the standard $125 copayment for the CT scan. The CT 
scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The 
records show that you were charged the in-network rate. 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 CT scan provided on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromonitoring services (95938, G0453, 95939) provided 
May 29, 2020. 
 
You asked the Plan to pay for the neuromonitoring services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the codes 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. 
 
We find that CPT code 95938, G0453, & 95939 is not supported in the medical record. Specifically, the claim 
did not include a valid diagnosis code for the CPT codes billed. Based on this information, we decided that 
Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the 
Plan does not have to pay for neuromonitoring services (95938, G0453, 95939) provided May 29, 2020.