Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure (97112x3) provided on June 29, 
2020. 
 
You asked the Plan to pay for the therapeutic procedure. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation does not support the 
number of units 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. 
 
In this case, the CPT Code Manual definition of code 97112 is therapeutic procedure, 1 or more areas, each 15 
minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities. 
 
We asked our coder 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 therapeutic procedure. Our reviewer says that CPT code 
97112 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical 
records provided do not include sufficient documentation to indicate total time of 15 minutes was spent 
delivering Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, 
balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (x 
3) on June 29, 2020. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the 
Plan does not have to pay for the therapeutic procedure (97112x3) provided on June 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided on October 6, 
2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that the procedure was necessary 
for your surgery and 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 a $30 
copayment for each specialist visit for outpatient hospital services.  
 
You have been asked to pay a $30 copayment for specialist services. Specialist services fall within the 
outpatient hospital 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 specialist 
services provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 11, 2019. 
 
You asked the Plan to pay for the services provided. You say that you depend on the facility for timely 
notification of the enrollee's insurance coverage. The Plan denied your request. The Plan says the claim was 
received past the allowed timeframe. 
 
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 the services provided was not filed until September 21, 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 medical services provided on July 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four periodontal scalings and root planings, seven 
localized deliveries of antimicrobial agents, four gingival irrigations, implant maintenance procedures, and two 
drugs or medicaments dispensed in the office for home use provided on October 6, 2020. 
 
You asked the Plan to pay for the scalings and planings, localized deliveries of antimicrobial agents, gingival 
irrigations, implant maintenance procedures, and drugs or medicaments. You say that you would like to appeal 
these services. The Plan denied your request. The Plan says these services are not covered. The Plan also says 
that you were given a code specific breakdown of your dental benefits, and mailed a copy of your dental 
benefits, prior to this date of 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 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 four 
periodontal scalings and root planings, seven localized deliveries of antimicrobial agents, four gingival 
irrigations, implant maintenance procedures, and two drugs or medicaments dispensed in the office for home 
use provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth specialist visit provided on 
March 17, 2020.  
 
You asked the Plan to waive the copayment for the telehealth specialist visit. You say that you were never told 
there would be a copayment for the phone call. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 $40 
copayment for each covered specialist visit (including office visits to psychologists and psychiatrists). For this 
date of service, you have been asked to pay the allowed amount of the claim because this amount is less than 
the $40 copayment for the telehealth specialist visit. 
 
You have been asked to pay a $25.82 copayment for the telehealth specialist visit. The telehealth specialist visit 
falls within the Physician/Practitioner services, including doctor's office visits 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 telehealth specialist visit provided on March 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital care (99222) provided September 15, 2019. 
 
You asked the Plan to pay for the hospital care. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the claim has been filed untimely. 
 
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 the hospital care was not filed until September 18, 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 hospital care (99222) provided September 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on October 10, 2020. 
 
You asked the Plan to pay for the consultation. You say that you asked for a second opinion from this provider 
because the proposed treatment plan could have been burdensome to you. The Plan denied your request. The 
Plan says this service is not a covered benefit 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 
consultation (D9310) provided on October 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 8, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the progress note documents a detailed history. The 
Plan denied your request. The Plan says there was not a claim for the ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that a treating practitioner must have a face-to-face 
encounter with a beneficiary within the six months prior to prescribing items that appear on the Required List. 
 
We find that the treating practitioner did not have a face-to-face encounter with the enrollee within the six 
months prior to prescribing the orthosis. Based on this information, we decided that Medicare rules for 
coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the 
lumbar-sacral orthosis provided on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided on September 3, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the surgery was not 
performed on this date. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The documentation submitted shows that the surgical services were 
provided on September 1, 2020. However, the claim for assistant surgeon services was billed for September 3, 
2020. The assistant surgeon services should be billed with the same date of service as the primary surgery. 
Medicare records were not provided to show that Medicare coverage criteria have been met. Therefore, we 
decided that the Plan does not have to pay for the assistant surgeon services provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 17, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
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 the services was not filed until September 18, 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 services provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on September 1, 
2020. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you should not owe the 
copayment because you had a diabetic nail trim. 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 $50 
copayment for podiatry services.  
 
You have been asked to pay the allowed amount of $45.55, which is less than the $50 copayment for podiatry 
services. Podiatry services fall within the podiatry 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 podiatry services provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 14, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is 
important to know which providers are part of our network because, with limited exceptions, while you are a 
member of our Plan you must use network providers to get your medical care and services. The only exceptions 
are emergencies, urgently needed services when the Plan's network is not available (generally, when you are 
out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network 
providers. 
 
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 
physician's 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 physician's services provided on October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on February 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on 
February 21, 2020. 
 
You asked the Plan to pay for the moderate sedation 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. 
 
In this case, the CPT Code Manual definition of code 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service). 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, this code was billed with 
place of service 22 (outpatient hospital). This code has a physician fee schedule professional 
component/technical component indicator of 3. Radiology and other diagnostic services furnished to hospital 
outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hopsital. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99153 
provided on February 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 
27, 2020, to July 28, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 a $200 
copayment for inpatient hospital care.  
 
You have been asked to pay the allowed amount of $78.04, which is less than the $200 copayment for inpatient 
hospital care. Inpatient hospital care falls within the inpatient hospital 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 inpatient hospital care provided from July 27, 2020, to July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and core buildup, including any pins when 
required provided on August 17, 2020. 
 
You asked the Plan to pay for the crown and core buildup. You say that this provider has not dropped 
Medicare, and you were reimbursed when you had your teeth cleaning. The Plan denied your request. The Plan 
says this provider opted out of Medicare effective from October 1, 2016, to October 1, 2022. The Plan also says 
that payment cannot be issued for services performed by a provider who has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules 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 at issue in this appeal 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 pay for the crown 
and core buildup, including any pins when required provided on August 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 29, 2020. 
 
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 September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 
25, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that your cleaning and exam should be 
covered in full. 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 
periodontal maintenance (D4910) provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 2, 2019. 
 
You asked the Plan to pay for the services provided. You say that you depend on the facility for timely 
notification of the enrollee's insurance coverage. The Plan denied your request. The Plan says the claim was 
received past the allowed timeframe. 
 
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 the services provided was not filed until September 15, 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 medical services provided on September 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard, 6 crowns, 3 periodontal scalings and 
root planings of four or more teeth, and periodontal scaling and root planing of one to three teeth to be provided 
by an OON provider. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has severe grinding, and you 
would like these services to be approved. The Plan denied your request. The Plan says services provided by an 
OON or non-contracted provider are not provided under the enrollee's benefit program. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard, 6 crowns, 3 periodontal scalings and root planings of four or more teeth, and periodontal 
scaling and root planing of one to three teeth to be provided by an OON provider.