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

 
We decided that the Plan does not have to pay for the medical services provided on June 19, 2020 by an out of 
network (OON) provider. 
 
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 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 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 19, 2020 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99601, CPT 99602) provided on February 
28, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Procedure codes 99601 and 99602 are assigned a status indicator of 
I under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. 
Medicare uses another code for reporting of, and payment for, these services. 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 99601, CPT 99602) provided on February 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided. 
 
You asked the Plan to pay for the dental service. You say that this service should be covered under the code for 
your consultation. You also say that someone at the office entered the wrong code. The Plan denied your 
request. The Plan says unspecified preventive service is not listed as a covered service. The Plan also says any 
services not listed 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. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventive service (D1999) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services rendered on October 10, 2019. 
 
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 codes 00797 and 64488 are 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 00797 is anesthesia for intraperitoneal procedures in 
upper abdomen including laparoscopy; gastric restrictive procedure for morbid obesity. The definition of code 
64488 is Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by 
injections (includes imaging guidance, when performed). 
 
We find that CPT codes 00797 and 64488 are not supported in the medical record. Specifically, there is no 
documentation of anesthesia performed for an intraperitoneal procedure to support code 00797. There is no 
documentation of a bilateral TAP block performed to support code 64488. 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 pain management services rendered on October 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on June 1, 2020.You asked the Plan to pay fortheseservices. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 80157, 80177, 80201, 80162, 80159 and 80173 are 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.We find that CPT codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical record. Specifically, there is no documentation of testing on blood specimens. 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 forthe laboratory services rendered on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aid repair services provided on April 30, 2020. 
 
You asked the Plan to pay for the hearing aid repair services. The Plan denied your request. The Plan says this 
service is not covered by Medicare or by your Plan. 
 
Medicare does not pay for hearing aids or related services. The contract with the Plan says that repair of 
hearing aids and related services are not covered. 
 
We looked at the file and the Plan's rules. The file shows that repair of hearing aids and related services are not 
covered. Therefore, we decided that the Plan does not have to pay for hearing aid repair services provided on 
April 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on June 30, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for an x-ray. 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. 
 
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 an x-ray provided on June 30, 2020 by an out of 
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services rendered on October 11, 2018. 
 
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 filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until July 16, 2020. A valid Waiver of Liability 
(WOL) was not received until August 10, 2020. This means that more than one calendar year from the date of 
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the 
physician services rendered on October 11, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), complete series of 
intraoral x-rays (D0210), prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on 
July 16, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, complete series of intraoral x-rays, prophylaxis, and 
topical application of fluoride varnish. You say that you were not advised that you would need to keep the 
dental rider every month in order to use the $1,000 annual maximum. You also say that you were led to believe 
the wrong information regarding the $1,000 maximum. The Plan denied your request. The Plan says your 
annual maximum dental benefit has been exhausted. The Plan also says that you chose not to enroll in the rider, 
with the understanding that you were only covered up to $500. 
 
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 Plan offers a $500 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on March 12, 2020 and your annual maximum benefit has been exhausted. The record shows 
that on July 10, 2020 you were advised by the Plan that the $1,000 annual maximum from the dental rider and 
the $500 supplemental dental benefit maximum could not be combined. Therefore, we decided that the Plan 
does not have to pay for the periodic oral evaluation (D0120), complete series of intraoral x-rays (D0210), 
prophylaxis (D1110), and topical application of fluoride varnish (D1206) provided on July 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care, per day, for the evaluation and 
management of a patient. 
 
You asked the Plan to pay for physician?s initial hospital care service (99223). You say that the Plan should 
pay this claim. The Plan denied your request. The Plan says the enrollee's hospital services were approved at 
the observation level of care not inpatient level of care. 
 
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 99223 is Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the hospital services were 
observation level, therefore this claim cannot be paid at an inpatient level. Based on this information, we 
decided that Medicare rules for coverage of initial hospital care (99223) have not been met. Therefore, we 
decided that the Plan does not have to pay for initial hospital care, per day, for the evaluation and management 
of a patient.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on April 27, 2020.You asked the Plan to pay forthese 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. The rules say that a professional component (PC)/technical component (TC) indicator of 9 represents a code for which the concept of a professional/technical component does not apply.We looked at the file and Medicare rules. The billed procedure codes have a PC/TC indicator of 9. There is no professional component for these codes. Payment is included in payment to the facility.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on April 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 21, 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 codes 80157, 80159, 80162, 80173, 80177 and 80201 are 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. 
 
We find that CPT codes 80157, 80159, 80162, 80173, 80177 and 80201 are not supported in the medical 
record. Specifically, there is no documentation of testing on blood specimens. 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 laboratory services rendered on April 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 21, 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 codes 80157, 80177, 80201, 80162, 80159, and 80173 are 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. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, there is no documentation of the testing being performed on blood specimens. 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 laboratory services rendered on April 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the pain management office visit and 
injectable drugs you received on August 3, 2020. 
 
You asked the Plan to waive the cost sharing for the pain management office visit and injectable drugs. You 
say that you have gotten these services in the past and have not had cost sharing. The Plan denied your request. 
The Plan says you were charged these copayment 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 $40 
copayment for specialist visits and 20% coinsurance for Medicare Part B drugs.  
 
You have been asked to pay a $40 copayment for the pain management office visit and 20% coinsurance for 
the injectable drugs you received. These cost sharing amounts apply regardless of whether you have been 
charged for them in the past. 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 pain management 
office visit and injectable drugs you received on August 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 1, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 October 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the dental services provided on July 15, 
2020. 
 
You asked the Plan to pay the in network rate for the dental services on July 15, 2020. You say that the services 
you received were processed incorrectly. You also say that the provider in this case is in network with the plan. 
The Plan denied your request. The Plan says palliative emergency treatment of dental pain 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in 
network rate for the dental services provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing test provided on August 24, 2020. 
 
You asked the Plan to pay for the hearing test. You say that you would like reconsideration because you did not 
receive a hearing test. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan does not pay 
for provider visits to service hearing aids.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing test have not been met. Specifically, the record indicates that this visit was for a 
hearing aid check. This is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a 
hearing test provided on August 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychiatric diagnostic evaluation with medical services. 
 
You asked the Plan to pre-approve the psychiatric diagnostic evaluation with medical services. The Plan denied 
your request. The Plan says limited to the specialists, ancillary providers, and hospitals available within the 
PCP?s IPA or medical group. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
psychiatric diagnostic evaluation with medical services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 28, 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 codes 80157, 80177, 80201, 80162, 80159 and 80173 are 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. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical 
record. Specifically, there is no documentation of testing on blood specimens. 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 laboratory services rendered on May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, endosteal implant, bone replacement graft for 
ridge preservation, and intravenous moderate (conscious) sedation/analgesia services provided on August 24, 
2020. 
 
You asked the Plan to pay for the extraction, endosteal implant, bone replacement graft, and sedation/analgesia 
services. You say that you had no option but to have these services completed. You also say that you had 
already depleted your dental funds for the year, which caused you a hardship. The Plan denied your request. 
The Plan says your dental allowance for the 2020 plan year has been exhausted. 
 
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 Plan offers a $2,000 annual dental 
allowance. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on July 1, 2020, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the extraction, endosteal implant, bone replacement graft for 
ridge preservation, and intravenous moderate (conscious) sedation/analgesia services provided on August 24, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for pathology services you received on July 13, 
2020. 
 
You asked the Plan to waive the copayment for the pathology services. You say that you shouldn't have to pay 
this copayment because there was a copay waiver in effect. The Plan denied your request. The Plan says they 
are only waiving copayments for office visits.  There is no copayment waiver for lab services. 
 
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 lab services.  
 
You have been asked to pay a $20 copayment for the pathology services. The pathology services fall within the 
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 pathology services you 
received on July 13, 2020.