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

We decided that the Plan does not have to pay for the core buildup, including any pins when required provided 
on July 14, 2020. 
 
You asked the Plan to pay for the core buildup. You say that you would like this service covered under your 
medical coverage rather than dental, because the service was caused by medical treatment. 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. This service is dental in nature, and is not covered under your medical 
benefits. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins 
when required provided on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG's, coronary angiography and CT 
angiography provided from October 8, 2019, through January 17, 2020. 
 
You asked the Plan to waive the copayment for the EKG's, coronary angiography and CT angiography. You 
say that these were pre-surgical workup services or post-operative follow ups. The Plan denied your request. 
The Plan says the copayments 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 $120 
copayment for each covered diagnostic procedure or test and diagnostic radiology services at a network 
outpatient facility and a $350 copayment for each covered surgery or observation room service in an outpatient 
hospital.
 
You have been asked to pay a total of $670.32 for the EKG's, coronary angiography and CT angiography.  
 
Date of Service Service Allowed Amount Standard 
Copayment 
Member Liability 
October 8, 2019 EKG $80.32 $120 $80.32 
November 4, 2019 Coronary 
Angiography 
$4,038.33 $350 $350 
November 26, 2019 CT Angiography $554.48 $120 $120 
January 17, 2020 EKG $709.82 $120 $120 
TOTAL:    $670.32 
 
The EKG's and CT angiography fall within the "Outpatient diagnostic tests and therapeutic services and 
supplies" benefit category. The coronary angiography 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 the EKG's, coronary angiography and CT angiography provided 
from October 8, 2019, through January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unattended electrical stimulation therapy provided on 
January 22, 2020 billed with code 97014. 
 
You asked the Plan to pay for the electrical stimulation as billed. You say that the services provided should be 
covered. The Plan denied your request. The Plan says code 97014 is not a valid Medicare code. 
 
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 97014 has a status indicator of "I" in the Physician Fee Schedule, meaning that it is 
invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage 
of the electrical stimulation as billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the unattended electrical stimulation therapy provided on January 22, 2020 billed with code 97014.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening bone densitometry (77080) provided on July 1, 
2020. 
 
You asked the Plan to pay for screening bone densitometry. You say that this should be covered. The Plan 
denied your request. The Plan says this is not covered for screening purposes. 
 
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 test at issue in this appeal, screening bone densitometry, 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 screening bone densitometry (77080) provided on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on March 4, 2019 
by the Hospital. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 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 out of network physician 
services provided on March 4, 2019 by the Hospital.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental item. You say that the lower denture was denied due to the 
enrollee having implants on the lower ridge. You say that the enrollee's treatment plan is for a conventional 
lower denture, not an implant supported denture. The Plan denied your request. The Plan says a complete lower 
denture is fabricated to fit in the mouth with no teeth present. The Plan says that a complete lower denture will 
not fit in your mouth properly with these implant attachments. The Plan also says a specially made denture with 
implant supports must be made. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the dental 
item when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental item. Our reviewer says that 
 
 
the requested complete lower denture is not medically necessary. Our physician reviewer found the requested 
complete lower denture is to be used where a denture is to be placed over natural bone and tissue in the absence 
of any teeth. The reviewer found that this would not be appropriate for the given clinical situation. The 
reviewer found that the provided documentation shows the enrollee has 3 lower anterior implants and no other 
teeth in either arch. Therefore, the reviewer found that the criteria for the request has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental item have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a complete lower denture (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient admission. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not require monitoring by doctors or nurses due to medical conditions. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee presented to the emergency room after a fall. The documentation did not 
support a newly diagnosed or suspected bone, muscle, joint or orthopedic device infection, or a vertebral 
fracture. She was treated with analgesics for pain control. The enrollee was hemodynamically and 
neurologically stable.  She did not require or receive any inpatient diagnostic studies or therapeutic 
interventions. The records do not show that the enrollee has a condition that requires an inpatient level of care. 
Therefore, an inpatient hospital admission is not medically reasonable or necessary to treat the enrollee. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an acute inpatient admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87631, 
87640, 87798, G2023, U0004) provided April 24, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 the lab services are not supported in the medical record. Specifically, the records do not include a 
valid physician order, and the claim form indicates a Place of Service of 81 (laboratory) however the 
documentation provided indicates the service was performed in a skilled nursing facility. Clarification was 
requested by the plan and no new documentation was provided. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87631, 87640, 87798, G2023, U0004) 
provided April 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), four gingival 
irrigations (D4921 x4), four periodontal procedures (D4999 x4), and local anesthesia in conjunction with 
operative or surgical procedures (D9215 x2) provided. 
 
You asked the Plan to pay for the oral hygiene instructions, gingival irrigations, periodontal procedures, and 
local anesthesia. You say that you received a cleaning, which you were told would be covered at 80%. You 
also say that your teeth became sensitive during the cleaning and you needed a shot. The Plan denied your 
request. The Plan says these services are not covered benefits under your dental plan. 
 
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 oral 
hygiene instructions (D1330), four gingival irrigations (D4921 x4), four periodontal procedures (D4999 x4), 
and local anesthesia in conjunction with operative or surgical procedures (D9215 x2) provided.  
 
Your complaint about possibly being given misinformation by the Plan is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on February 4, 
2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you had COVID-19 symptoms so 
the copayment should be waived. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on 
February 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 16, 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 July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 10, 2020. 
 
You asked the Plan to pay for the dental service. The Plan denied your request. The Plan says 1 panoramic x-
ray every 3 plan years is covered. The Plan also says that the frequency limit 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, the frequency limit of 1 panoramic x-
ray every 3 plan years has been exceeded. The record shows that the Plan paid for the panoramic x-ray that you 
received on December 4, 2019, thus exhausting the benefit. Therefore, we decided that the Plan does not have 
to pay for the panoramic x-ray (D0330) provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the placement of a pacemaker provided on 
May 28, 2020. 
 
You asked the Plan to waive the coinsurance for the placement of a pacemaker. You say that you cannot afford 
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 30% 
coinsurance for out-of-network outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers.  
 
You received the placement of a pacemaker on May 28, 2020 from an out-of-network provider. Therefore, you 
are responsible to pay $6,902.26, which is less than the 30% coinsurance amount.  
 
You have been asked to pay $6,902.26 for the placement of a pacemaker. The placement of a pacemaker 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 coinsurance for the placement of a 
pacemaker provided on May 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the SNF services are medically necessary. The 
Plan denied your request. The Plan says coverage criteria is not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for cardiology services you received on April 
7, 2020, and May 12, 2020. 
 
You asked the Plan to waive the copayments for the cardiology services. You say that you did not know you 
would be charged a copayment every time your cardiologist read the monitor in your chest. You said that you 
did not visit this doctor on these dates and it shouldn't be considered telehealth. The Plan denied your request. 
The Plan says you were charged these copayments 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 $45 
copayment for visits to a specialist.  
 
You have been asked to pay a $45 copayment for the cardiology services. The cardiology services fall within 
the visits to a specialist benefit category because your contract clearly states that the specialist copayment 
applies to remote evaluation services such as the reading of your chest monitor. 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 copayments for cardiology services you received on April 7, 2020, and May 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the elbow x-ray provided on June 22, 2020. 
 
You asked the Plan to waive the copayment for the elbow x-ray. You say that you broke your elbow at the 
hospital. You say that the hospital should cover all the bills. 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 $35 per 
day, per in-network provider, for Medicare-covered x-ray services.  
 
You have been asked to pay $29.31, which is less than the standard $35 copayment for the elbow x-ray. The 
elbow x-ray 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 the elbow x-ray provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient assisted living visit (99334) provided 
on August 13, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. You say that the services provided 
were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by 
the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient assisted living visit (99334) 
provided on August 13, 2020, by an out of network (OON) provider.