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

 
We decided that the Plan does not have to waive the coinsurance for an injection of denosumab provided on 
May 27, 2020. 
 
You asked the Plan to waive the coinsurance for injection. You say that you were told this would be covered 
and were not informed about cost-sharing. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for in-network injection. The allowed amount of this injection is $1,160.40, resulting in a 
coinsurance obligation of $232.08. 
 
You have been asked to pay 20% coinsurance for injection. Injection falls within the Medicare Part B 
Prescription Drugs 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 injection of 
denosumab provided on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5211) and mandibular partial 
denture (D5212) provided on June 1, 2020. 
 
You asked the Plan to pay for the maxillary partial denture and mandibular partial denture. You say that your 
dentist suggested new dentures because you were not able to chew. You also say that the replacement was 
necessary. 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 
maxillary partial denture (D5211) and mandibular partial denture (D5212) provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care office visit provided on 
March 5, 2020. 
 
You asked the Plan to waive the copayment for office visit. You say that this was a routine examination and 
you are entitled to 1 free annual routine physical per year. 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 $20 
copayment for in-network primary care visit. The record shows that this visit included both a preventive exam 
as well as a non-preventive office visit, therefore an office visit with applicable copayment was billed in 
addition to the preventive examination. 
 
You have been asked to pay $20 copayment for office visit. Office 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 primary care office visit provided on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on March 2, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with 
suspension sleeve (L1833, L2397) provided to the enrollee on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on April 20, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service April 20, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for Guardant360 testing provided on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ophthalmology visits you had on 
November 18, 2019, December 30, 2019, and April 10, 2020. 
 
You asked the Plan to waive the copayments for the ophthalmology visits. You say that have never had a 
copayment for this service in the past. 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 $30 
copayment for specialist visits.  
 
You have been asked to pay a $30 copayment for each of the ophthalmology visits. The ophthalmology visits 
fall within the specialist 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 copayments for the 
ophthalmology visits you had on November 18, 2019, December 30, 2019, and April 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 16, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 16, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on April 
16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on February 28, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the OON drug testing. You say that this testing was medically necessary as 
ordered by the treating physician. The Plan denied your request. The Plan says the enrollee self-referred to an 
OON physician and this testing was provided out of network without prior authorization. The denial of 
payment is correct. 
 
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 definitive drug testing provided on February 
28, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), core buildup  
(D2950), re-cement or re-bond fixed partial denture (D6930), two restorative procedures (D2999 x2), problem 
focused limited oral evaluation (D0140), adjunctive procedure (D9999), and extraction (D7140) provided from 
March 19, 2020 to April 15, 2020 by an OON provider. 
 
You asked the Plan to pay for the dental services. You say that your insurance paid $0 for these services, and 
you paid $575. 
 The Plan denied your request. The Plan says the core buildup, re-cement or re-bond fixed partial denture, 
restorative procedure, problem focused limited oral evaluation, and adjunctive procedure are not covered 
benefits. The Plan also says that the appropriate amounts of $14 for the first intraoral periapical x-ray and $65 
for the extraction were applied as outlined in the Evidence of Coverage. 
 
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 core buildup, re-cement or re-bond 
fixed partial denture, restorative procedure, problem focused limited oral evaluation, and adjunctive procedure 
are not among those covered under this benefit. The contract clearly states that you are responsible for a $25 
copay for dental x-rays, and a $40 copay for dental extractions. The contract also states that you may be 
charged more if you receive services from an OON provider.  
 
The record shows that the allowable amount for the first intraoral periapical x-ray was $14, which is less than 
the copay, and therefore, your responsibility is $14. The record also shows that you are responsible for a $40 
copay for extractions, and you received this service OON. You are responsible for the difference between the 
billed and allowed amounts, as well as the $40 copay. Therefore, we decided that the Plan does not have to pay 
for the first intraoral periapical x-ray (D0220), core buildup  (D2950), re-cement or re-bond fixed partial 
denture (D6930), two restorative procedures (D2999 x2), problem focused limited oral evaluation (D0140), 
adjunctive procedure (D9999), and extraction (D7140) provided from March 19, 2020 to April 15, 2020 by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special pump services rendered on February 25, 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded.  
 
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status 
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. 
Therefore, we decided that the Plan does not have to pay for the special pump services rendered on February 
25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sterile needles (A4215) provided on February 10, 2020. 
 
You asked the Plan to pay for the sterile needles. You say that you would like reconsideration because these 
services were requested by an In-network provider. The Plan denied your request. The Plan says the service 
code A4215 is excluded by Medicare per the National Correct Coding Initiative (CCI) policy and therefore not 
payable by Medicare. 
 
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 A4215 is not supported in the record. Specifically, payment for this service is packaged 
into the payment for other services rendered. Based on this information, we decided that Medicare rules for 
coverage of the sterile needles have not been met. Therefore, we decided that the Plan does not have to pay for 
sterile needles (A4215) provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia service provided on March 10, 2020. 
 
You asked the Plan to pay for anesthesia for percutaneous image guided procedures on the spine and spinal 
cord (01936). You say that the service was provided by a different provider. The Plan denied your request. The 
Plan says coverage guidelines were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. There are insufficient medical records to 
determine the service was billed correctly. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for the anesthesia service provided on 
March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) on June 1, 
2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the copayment should be 
waived because the provider's office could have provided your test results by phone. 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 $40 
copayment for each specialist visit for Medicare-covered benefits.  
 
You have been asked to pay a $40 copayment for a specialist office visit. A specialist office 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 specialist office visit (99213) on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 6, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria were not met. 
 
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 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 pay for this service. Our reviewer says that Medicare coverage criteria are not met. For Medicare to 
consider coverage and payment for any item or service, 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 this physician's review, the file, and Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we 
decided that the Plan does not have to pay for physician services provided to the enrollee on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient eye treatment services provided on January 6, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for specialists services. 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 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 outpatient eye treatment services provided on 
January 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment outpatient surgery you had at an 
ambulatory surgery center on March 4, 2020. 
 
You asked the Plan to waive the deductible and copayment the outpatient surgery. You say that this procedure 
was painful, so you should not have to pay for this. The Plan denied your request. The Plan says you were 
charged this amount correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that after you meet your $1,000 deductible, you pay a $200 copayment for 
outpatient surgery in an ambulatory surgical center. 
 
Records show that the cost of this surgery was $1,113.47.  You have an annual deductible of $1,000 that must 
be met before the Plan will pay anything.  Therefore, the first $1,000 of this amount is your deductible 
obligation.  The remaining $113.47 is less than you $200 copayment obligation for outpatient surgical services 
you receive in an ambulatory surgical center. This cost sharing is a contractual obligation and it applies 
regardless of your satisfaction with the services received. Therefore, we decided that the Plan does not have to 
waive the deductible and copayment outpatient surgery you had at an ambulatory surgery center on March 4, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the hand (73130) provided on June 18, 2020. 
 
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services were not emergent or pre-approved there were network providers 
available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 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 x-ray of the hand (73130) provided on June 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the consultation (D9310), cone beam CT capture 
(D0366), periapical x-ray (D0220) and root canal (D3320) provided on January 31, 2020. 
 
You asked the Plan to pay more for the consultation (D9310), cone beam CT capture (D0366), periapical x-ray 
(D0220) and root canal (D3320). You say that you were informed you could see any dentist or endodontist of 
your choice, pay out of pocket and submit a bill for reimbursement. You say that you should be compensated 
the difference. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 is only obligated to pay 70% 
of the allowed amount for the periapical x-ray and 50% of the allowed amount for the root canal. You are 
responsible for the difference billed and any non-covered services. Therefore, we decided that the Plan does not 
have to pay more for the consultation (D9310), cone beam CT capture (D0366), periapical x-ray (D0220) and 
root canal (D3320) provided on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 13, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the copayment 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 a $45 
copayment for each Medicare-covered specialist office visit.  
 
You have been asked to pay a $45 copayment for a specialist visit. A 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 specialist visit provided on May 13, 2020.