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

We decided that the Plan does not have to pay for the lab services provided on December 12, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 find that the billed CPT codes are not supported in the medical record. Specifically, the services were billed 
as if the specimen was collected by blood sampling. However, the records show that the specimen was 
collected by urine sample. 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 the lab services 
provided on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 17, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that the physician must 
clearly document, in the medical record, his or her intent that the test be performed. 
 
We find that the billed CPT codes are not supported in the medical record. Specifically, the services were billed 
as if the specimen was collected by blood sampling. However, the records show that the specimen was 
collected by urine sample. Additionally, the records provided do not contain a valid physician order or lab 
requisition stating exactly which drug testing was to be performed. 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 the lab services provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physician services rendered on 
October 21, 2019 to January 20, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the copayments were 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 $10 
copayment for each primary care doctor visit for Medicare covered benefits.  
 
Review of the file shows that you received primary care physician services on October 21, 2019 and January 
20, 2020. You have been asked to pay a $10 copayment per date of service for these services, for a total of $20. 
These services fall within the primary care doctor visit for Medicare covered benefits 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 copayments for the physician services rendered on October 21, 2019 to 
January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional payment for dental services provided on January 
16, 2020. 
 
You asked the Plan to approve additional payment for dental services. You say that you needed your teeth 
removed because you were in pain. The Plan denied your request. The Plan says that you have already received 
the maximum amount of coverage allowed for this type 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. The Plan covers up to a $1,000 
allowance for Non-Medicare covered dental services every year. 
 
We looked at the file and Medicare rules. The file shows that the plan has approved the maximum yearly 
benefit of $1,000 for the requested services. There is no provision in the contract which would require the plan 
to approve more than this amount. Therefore, we decided that the Plan does not have to approve additional 
payment for dental services provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a dermatology office visit provided on June 
23, 2020. 
 
You asked the Plan to waive the copayment for specialist visit. You say that this was a follow-up visit which 
should be included as part of the surgery, so you should not have a separate copayment. The Plan denied your 
request. The Plan says the copayment amount you are being charged is correct. 
 
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 $40 
copayment for specialist visit.  
 
You have been asked to pay $40 copayment for specialist visit. 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 a dermatology office visit provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the hospital outpatient clinic visit for assessment and management provided on February 3, 2020.
You asked the Plan to adjust the copayment for the hospital outpatient clinic visit (G0463). You say that the copayment should only be $20. 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 $215 copayment for Outpatient hospital services. You have been asked to pay a $119.14 copayment, less than your required copayment, for the hospital outpatient clinic visit (G0463). The hospital outpatient clinic visit (G0463) falls 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 adjust the copayment for the hospital outpatient clinic visit for assessment and management provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance charged for injection services provided on March 12, 2020.

You asked the Plan to waive this coinsurance. You say that you do not believe this cost share is correct. The Plan denied your request. The Plan says this cost share was charged based on the services provided and the Plan contract agreement.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs such as injections. 

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 20% coinsurance charged for injection services provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 3, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services should be covered because they 
were medically necessary.  In addition, you stated that the medical records support the level of care billed. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 March 3, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #30 (D2750) and core buildup 
(D2950), 
 
You asked the Plan to pre-approve the crown and core buildup. You say that you would like reconsideration 
because these services are medically necessary. The Plan denied your request. The Plan says the member does 
not meet Plan criteria for coverage of these services. 
 
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. The Plan covers the crown and 
core buildup 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 crown and core buildup. Our 
reviewer says that there is only a tiny area of worn structure that can easily be restored with a composite 
restoration.  There is no pathologic destruction by caries or trauma that involves four or more surfaces or two 
or more cusps.  There is no need to place a crown on a tooth where the preparation of the tooth would cause 
significant damage to the remaining structure just to place the restoration. Our physician reviewer found there 
is no medical necessity for a crown in this instance, and the Plan criteria have not been met. 
 
Additionally, Per the EOC, core buildup (D2950) is not a covered benefit. 
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 crown and core buildup have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a crown for tooth #30 (D2750) and core buildup (D2950).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy of the esophagus, stomach, and/or 
upper small bowel using an endoscope (43239) on April 22, 2019. 
 
You asked the Plan to waive the copayment for a biopsy of the esophagus, stomach, and/or upper small bowel. 
You say that you did not receive this service and only received a routine colonoscopy on April 22, 2019. 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 $350 
copayment for each covered surgery in an outpatient hospital. 
 
You have been asked to pay a $350 copayment for a biopsy of the esophagus, stomach, and/or upper small 
bowel. The provider supplied medical records documenting that a biopsy of the esophagus, stomach, and/or 
upper small bowel was performed on April 22, 2019. A biopsy of the esophagus, stomach, and/or upper small 
bowel, when performed in an outpatient hospital, 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 a biopsy of the esophagus, stomach, and/or upper small bowel using 
an endoscope (43239) on April 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation, intraoral x-ray, cone beam CT capture and retreatment of root canal therapy provided on April 1, 2020.

You asked the Plan to reimburse you for the limited oral evaluation, intraoral x-ray, cone beam CT capture and retreatment of root canal therapy. You say that the procedure was for a life-threatening sinus cavity abscess. You say that you paid out of pocket and are looking for reimbursement due to the medical nature of the treatment. The Plan denied your request. The Plan says you have already received the maximum amount of coverage allowed.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of $1,000 toward preventive and comprehensive dental services every year. The Plan paid $1,000 toward dental services you received on February 13, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation, intraoral x-ray, cone beam CT capture and retreatment of root canal therapy provided on April 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on April 15, 2020.

You asked the Plan to pay for this service. You say that the Plan should cover these services. The Plan denied your request. The Plan says this provider is not a Medicare eligible provider.

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. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided on April 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided on March 25, 2020.

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 the provider is not eligible to take Medicare payment.

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. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided on March 25, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided on April 9, 2020. 
 
You asked the Plan to pay for this service. You say that the Plan should pay for these services. The Plan denied 
your request. The Plan says you chose a provide who is not eligible to accept Medicare payment. 
 
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. This provider has opted out of the Medicare program. 
Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided on April 9, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electronic analysis of an implanted neurostimulator pulse 
generator/transmitter (95971-51) provided on September 9, 2019. 
 
You asked the Plan to pay for the electronic analysis. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says CPT code 95971 was billed with an 
inappropriate modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
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 electronic analysis. Our reviewer says that CPT code 
95971 was billed with invalid modifier 51. Our reviewer found Multiple Procedure (Modifier 51) Indicators 
indicates which payment adjustment rule for multiple procedures applies to the service: 0 = No payment 
adjustment rules for multiple procedures apply.  If procedure is reported on the same day as another procedure, 
base payment on the lower of (a) the actual charge or (b) the fee schedule amount for the procedure. 
 
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 electronic analysis have not been met. Therefore, we decided that the Plan 
does not have to pay for an electronic analysis of an implanted neurostimulator pulse generator/transmitter 
(95971-51) provided on September 9, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on July 11, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says records were not 
provided. 
 
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 does not contain records for the date of 
service in question. Without records, it cannot be determined that Medicare coverage criteria have been met. 
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 provided on July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CPAP supplies provided from January 
31, 2019 to January 22, 2020. 
 
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that you dispute these charges. 
The Plan denied your request. The Plan says that this was processed and paid 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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for the CPAP supplies. The CPAP supplies fall within the 
durable medical equipment (DME) and related supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for the CPAP supplies provided from January 31, 2019 to January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical supplies reported under revenue code 0272 for 
date of service January 10, 2020. 
 
You asked the Plan to pay for the medical supplies. You say that the claim should be processed to pay in full. 
The Plan denied your request. The Plan says this was not coded properly as A6212. 
 
The Plan must follow Medicare rules. Medicare rules say that outpatient hospital claims must include HCPCS 
codes for all items/services rendered.  
 
In this case, a charge of $35.12 was reported under revenue code 0272 without a corresponding HCPCS code. 
This is not correctly billed. Therefore, we decided that the Plan does not have to pay for the medical supplies 
reported under revenue code 0272 for date of service January 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a 
participating provider on March 11, 2020. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you were informed that 
you would stay overnight after your surgery. The Plan denied your request. The Plan says the correct 
coinsurance 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 20% 
coinsurance for outpatient surgery/in-network/covered surgery or observation room service.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total 
allowed is $3,322.20. The total amount you are being asked to pay is $664.41 ($3,322.20 x 20% = $664.41). 
The correct coinsurance has been applied. An outpatient surgery falls within the outpatient surgery/in-
network/covered surgery or observation room service 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 an outpatient surgery provided by a participating provider on March 11, 2020.