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

We decided that the Plan does not have to pay forblood bank physician services provided on April 23, 2020.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says the code was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code willbe denied.In this case, the MUE for CPT code 86077is 1.You billed 2units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met.Therefore, we decided that thePlan does not have to pay forblood bank physician services provided on April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's 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 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation, intraoral x-ray, pulp vitality 
tests and root canal provided on April 30, 2020 and core buildup provided on June 1, 2020 by out-of-network 
providers. 
 
You asked the Plan to pay more for the limited oral evaluation, intraoral x-ray, pulp vitality tests, root canal 
and core buildup. You say that insurance agreed to pay 50% but the dentist hasn't gotten paid. 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 the 
full cost of your covered preventive and diagnostic services, 20% of the allowed amount for basic dental 
services and 50% of the allowed amount for major dental services. You will pay more if you get care from an 
out-of-network provider. 
 
Date of 
Service 
Service Billed 
Amount 
Allowed 
Amount 
Copayment/ 
Coinsurance 
Difference of 
Billed & Allowed 
Amount 
Member 
Liability 
April 30, 2020 Oral 
Evaluation 
$95 $45.60 $0 $49.40 $49.40 
April 30, 2020 X-Ray $45 $23 $0 $22 $22 
April 30, 2020 Pulp Tests $30 $0 $0 $30 $30 
April 30, 2020 Root Canal $1,230 $466.77 $233.36 $763.23 $996.62 
June 1, 2020 Core Buildup $383 $67 $13.40 $316 $329.40 
TOTAL:      $1,427.42 
 
Out-of-network providers are not required to accept the plan's rate as payment in full. Therefore, we decided 
that the Plan does not have to pay more for the limited oral evaluation, intraoral x-ray, pulp vitality tests and 
root canal provided on April 30, 2020 and core buildup provided on June 1, 2020 by out-of-network providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, retrograde 
filling, and apicoectomy provided from October 30, 2019, to November 26, 2019. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, retrograde filling, and apicoectomy. 
You say that you would like to be reimbursed because these services were medical in nature. The Plan denied 
your request. The Plan says these services are dental in nature, and are not covered under your plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral 
evaluation, retrograde filling, and apicoectomy provided from October 30, 2019, to November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services rendered on July 1, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you were seen for diabetic 
neuropathy. The Plan denied your request. The Plan says the copayment was 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 $40 
copayment for each Medicare-covered podiatry visit.  
 
Review of the file shows that you received podiatry services on July 1, 2020. You have been asked to pay a $40 
copayment for these services. These services fall within the Medicare-covered podiatry visit 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. 
 
The file shows that the podiatry services were rendered for a diagnosis of diabetic neuropathy. These services 
are not considered routine foot care. Therefore, we decided that the Plan does not have to waive the copayment 
for the podiatry services rendered on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on February 20, 2020. 
 
You asked the Plan to pay for the physician's 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 
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 that you provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction provided on June 2, 2020.

You asked the Plan to pay for the surgical extraction. You say that you feel that this service was medically necessary. The Plan denied your request. The Plan says your dental coverage does not include coverage for surgical extractions.

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 surgical extraction provided on June 2, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99291, 99053, 93010, 31500) 
provided March 14, 2020. 
 
You asked the Plan to pay for the emergency room services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the claim did not include a valid primary diagnosis. 
 
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 99291, 99053, 93010, and 31500 is not supported in the medical record. Specifically, 
CPT code 93010 shares a Column I / Column II relationship with CPT code 31500. Additionally, a secondary 
only diagnosis code was submitted as the primary diagnosis code. Based on this information, we decided that 
Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99291, 99053, 93010, 31500) provided March 14, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says physical therapy or other services other than manual manipulation are 
not covered by Medicare or the Plan when provided in a chiropractic setting.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sixty minutes of psychotherapy (90837) provided on 
January 7, 2020 to January 28, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by 
an out-of-network provider. 
 
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 sixty minutes of psychotherapy (90837) 
provided on January 7, 2020 to January 28, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient mental health services provided on April 3, 
2020, to April 6, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the inpatient mental health services. 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 inpatient mental health services provided on 
April 3, 2020, to April 6, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for a drug test provided on February 7, 
2020. 
 
You asked the Plan to pay for the physician's services for a drug test. 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 
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 physician's services for a drug test provided on February 7, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound behind abdominal cavity (76770) provided on 
March 13, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the ultrasound behind abdominal cavity. 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 ultrasound behind abdominal cavity (76770) 
provided on March 13, 2020, by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician stand by services coded 99360, the needle 
electromyography services coded 95870, and the short-latency somatosensory evoked potential study services 
coded 95938 provided on December 19, 2019. 
 
You asked the Plan to pay for the physician stand by services, the needle electromyography services, and the 
short-latency somatosensory evoked potential study 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. 
 
We find that CPT codes 99360, 95870, and 95938 are not supported in the medical record. Specifically, code 
99360 has a status code of "X"; therefore, this code is not payable. Codes 95870 and 95938 have a physician 
Fee Schedule PCTC indicator of 1 and the claim a place of service of 22 ? Outpatient hospital. The 
professional interpretation was furnished in the same payment locality from where the TC was furnished. We 
find that the Medicare rule for payment of this claim has not been met as the professional interpretation of a 
diagnostic test must be separately billed with modifier ? 26 by the interpreting physician. 
 
Based on this information, we decided that Medicare rules for coverage of the physician stand by services, the 
needle electromyography services, and the short-latency somatosensory evoked potential study services have 
not been met. Therefore, we decided that the Plan does not have to pay for the physician stand by services 
coded 99360, the needle electromyography services coded 95870, and the short-latency somatosensory evoked 
potential study services coded 95938 provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the outpatient services provided on July 21, 
2020. 
 
You asked the Plan to waive the copay for the services provided. You say that the copay is extreme. The Plan 
denied your request. The Plan says the claim processed 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 $200 
copay for outpatient surgery.  
 
The file shows that you received a joint injection. The services at issue are considered surgical services. You 
have been asked to pay a $200 copay for the services provided. The services fall within the outpatient surgery 
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 copay for the outpatient services provided on 
July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe unspecified adjunctive service (D9999), guided tissue regeneration (D4266), bone replacement graft (D4263), the extraction (D7210), 6 crowns (D2740), 6 core build up (D2950), 13 labial veneers (D2962), 2 abutment supported crowns (D6058), and 2 custom fabricated abutments (D6057) provided from July 15, 2019, to September 24, 2019.You asked the Plan to reimburse you forthe dental services. You say that you are concerned about your teeth and dry mouth. You say that the services should be covered under medical. You also say that you should be reimbursed for the services.The Plan denied your request. The Plan says the services you received are dental in nature. The Plan says there is a maximum allowance of $900 for non-Medicare covered preventive and comprehensive dental services. The Plan also says that the maximum allowance has been exhausted.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum allowance of $900 has been exhausted.The Evidenceof Coverage clearly states that you are responsible for any amount above the dental coverage limit.Therefore, we decided that the Plan does not have to reimburse you forthe unspecified adjunctive service (D9999), guided tissue regeneration (D4266), bone replacement graft (D4263), the extraction (D7210), 6crowns (D2740), 6 core build up (D2950), 13 labial veneers (D2962), 2 abutment supported crowns (D6058), and 2 custom fabricated abutments (D6057) provided from July 15, 2019, to September 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient testing provided. 
 
You asked the Plan to pay for the outpatient testing. You say that the office was not able to bill to the primary 
carrier due to the invalid coordination of benefits. You say that payment should be made. The Plan denied your 
request. The Plan says a claim is denied if it is not received by the plan within 12 months or 1 calendar year 
from the date when the services were rendered.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient testing. 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 outpatient testing provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 16, 2020 to February 21, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received inpatient hospital care on the dates of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 per day for days 1-7 for Inpatient hospital care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received inpatient 
hospital care from February 16, 2020 to February 21, 2020. You have been asked to pay a $200 copayment per 
day for days 1-5, totaling $1000. The inpatient hospital stay 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 the inpatient hospital stay provided from 
February 16, 2020 to February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) provided on 
June 1, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility 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 subsequent nursing facility visit (99308) 
provided on June 1, 2020, by an out of network (OON) provider.