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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of 
intraoral x-rays provided on July 23, 2020 by an OON provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you were advised that this facility you were seen at was in-network. You also say that you were not 
aware that the provider you saw was not in network. The Plan denied your request. The Plan says these services 
were rendered by an OON provider. The Plan also says that there are no calls on file showing that you were 
advised that this provider is in network. 
 
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 are responsible for 100% of the 
cost of covered services that you receive OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation and complete series of intraoral x-rays provided on July 23, 2020 by an OON 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a coronary artery disease risk assessment (81493) provided 
on May 19, 2020. 
 
You asked the Plan to pay for a coronary artery disease risk assessment. You say that this was required to treat 
the enrollee safely. The Plan denied your request. The Plan says this is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
 
 
The test at issue in this appeal, a coronary artery disease risk assessment, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for a coronary artery disease risk assessment (81493) provided on May 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the counseling (99406) and anesthesia services (00731) 
provided by an out of network (OON) provider. 
 
You asked the Plan to pay for OON counseling and anesthesia services. You say that you were not notified an 
authorization was needed. The Plan denied your request. The Plan says OON services require 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 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 counseling (99406) and anesthesia services 
(00731) provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse more for the crowns (D2740) for teeth # and core build up 
(D2950) provided. 
 
You asked the Plan to reimburse more for the dental services. You say that you received a letter notifying you 
of a change in the Plan name. You say that there was no mention of a change in benefits. You say that you have 
coverage for up to $2,000 for dental services. You also say that you should be reimbursed an additional $1,500 
for the services that you received. The Plan denied your request. The Plan says there is a $500 allowance every 
year for non-Medicare covered preventive and comprehensive dental services. The Plan also says that the 
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 $500 allowance for dental services 
has been exhausted.  
 
CPT Code Billed Amount Plan Paid Your Responsibility 
D0120 $33 $33 $0 
D0274 $45 $45 $0 
D1110 $58 $58 $0 
D1206 $25 $25 $0 
D0220 $13 $13 $0 
 
 
D0230 $9 $9 $0 
D0230 $9 $9 $0 
D2392 $155 $155 $0 
D2740 $598.40 $153 $440.40 
D2740 $989 $0 $989 
D2950 $148 $0 $148 
TOTAL:  $500 $1,137.40 
 
The record shows that the Annual Notice of Coverage for 2020 was issued on September 12, 2019 which 
advises the changes to the costs and benefits from 2019 to 2020, including the $500 allowance. Therefore, we 
decided that the Plan does not have to reimburse more for the crowns (D2740) for teeth # and core build up 
(D2950) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the two surgical extractions (D7210 x2) and six simple 
extractions (D7140 x6) provided on June 3, 2020. 
 
You asked the Plan to pay more for the extractions. You say that the only reason you added the dental rider to 
your plan was because you thought it began on June 1, 2020. You also say that you were under the assumption 
that these extractions would be paid. The Plan denied your request. The Plan says the total $115.00 coinsurance 
applied to each surgical extraction (D7210) was applied correctly. The Plan also says that your $1,000 benefit 
max was met during the processing of this claim. 
 
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 are responsible for a 50% 
coinsurance for extractions. The contract also clearly states that the Plan offers a $1,000 annual dental benefit 
maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit while processing this claim from the June 3, 2020 date of service, and your annual maximum 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the two surgical 
extractions (D7210 x2) and six simple extractions (D7140 x6) provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on January 
14, 2020. 
 
You asked the Plan to pay for the oral hygiene instructions. You say that you are shocked that the dentist would 
have a line item for tooth brushing instructions. You also say that the Plan needs to address this type of billing 
with the dentist. The Plan denied your request. The Plan says this service is not covered under your benefit 
plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral 
hygiene instructions (D1330) provided on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tlso flex trnk item coded L0457 provided. 
 
You asked the Plan to pay for the Tlso flex trnk item. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the documentation does not support that the prescribing 
physician had ever seen this enrollee. 
 
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 L0457 is Tlso, flexible, provides trunk support, thoracic 
region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates 
just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary 
pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, off-the-shelf. 
 
We find that CPT code L0457 is not supported in the medical record. Specifically, the documentation shows 
that the enrollee has not received any type of medical brace. In addition, the documentation supports that the 
prescribing physician had never seen or ordered a brace for the enrollee. There are no other claims from the 
ordering physician within the last six months prior to the date of service. Based on this information, we decided 
that Medicare rules for coverage of the Tlso flex trnk item have not been met. Therefore, we decided that the 
Plan does not have to pay for the Tlso flex trnk item coded L0457 provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 23, 2020 to June 2, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you didn't know the provider was not participating 
with the Plan. The Plan denied your request. The Plan says the services were rendered by an out-of-network 
provider without 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 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 April 23, 2020 to 
June 2, 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 the electrocardiogram (93010) provided on July 15, 2019. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration because this 
claim was initially submitted timely. The Plan denied your request. The Plan says this claim was received past 
the allowed 12 month 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 electrocardiogram was not filed until August 26, 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 electrocardiogram (93010) provided on July 15, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the interpretation of a single view x-ray of the femur provided. 
 
You asked the Plan to pay for the interpretation of the x-ray. You say that this was denied as duplicate in error. 
The Plan denied your request. The Plan says that procedure code 73551 is the Column II code to the Column I 
code 73552, which was billed by another physician in the same billing group. A modifier is allowed in order to 
differentiate between the services provided but was not used. 
 
The Plan must follow Medicare rules. Medicare rules say that PTP edits are based on services provided by the 
same physician to the same beneficiary on the same date of service. 
 
In this case, the two interpretations at issue were performed by two physicians for two distinct x-ray images. 
PTP edits do not apply to services performed by two different physicians, and as such, no modifier is required. 
Therefore, we decided that the Plan has to pay for the interpretation of a single view x-ray of the femur 
provided.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infectious agent detection (87801) provided December 12, 
2019. 
 
You asked the Plan to pay for the Infectious agent detection. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the diagnosis code used indicates a screening test. This 
test is not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the Infectious agent detection, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for Infectious agent detection (87801) provided December 12, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram interpretation and report (93010) 
provided on June 4, 2020. 
 
You asked the Plan to pay for the electrocardiogram interpretation and report. You say that you would like 
reconsideration because this is a payable service. The Plan denied your request. The Plan says review shows an 
interpretation and EKG strip completed, but it was not completed by the provider of the denied claim. 
 
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 the electrocardiogram interpretation and 
report. Our reviewer says that CPT code 93010 does not meet criteria for billing or reimbursement 
consideration. Our physician reviewer found the medical records submitted do not include documentation to 
corroborate that the electrocardiogram interpretation and report only was performed on the billed date of 
service by the billing provider. Therefore, CPT 93010 is considered a bundled service with CPT code 99285. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the electrocardiogram interpretation and report have not been met. Therefore, 
we decided that the Plan does not have to pay for the electrocardiogram interpretation and report (93010) 
provided on June 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from July 8, 2020, to 
July 10, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered. The Plan 
denied your request. The Plan says the drugs that you received are considered self-administered. The Plan says 
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
drugs you received are not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from July 8, 2020, to July 10, 2020.  
 
 
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture provided on July 15, 2020. 
 
You asked the Plan to pay for the mandibular partial denture. You say that you feel that some of this bill should 
be covered by the Plan. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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. The Plan only covers denture repairs and adjustments. The contract 
clearly states that new dentures are not covered. Therefore, we decided that the Plan does not have to pay for 
the mandibular partial denture provided on July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on July 28, 2020. 
 
You asked the Plan to pay for the services provided. You say that the ordering physician attested to the 
Medicare coverage criteria. The Plan denied your request. The Plan says to report a comprehensive genomic 
profile, test providers should use CPT code 81479. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the test at issue is not supported as billed on the claim. The provided claim does not show that the 
services were billed in accordance to Medicare guidelines. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the Guardant360 testing provided on July 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extremity veins (93970) provided May 19, 
2020. 
 
You asked the Plan to pay for the diagnostic services. You say that records attached supporting that this 
procedure was performed by your provider. The claim denied as duplicate in error. Please review and reprocess 
claim for reimbursement according to contract. The Plan denied your request. The Plan says claim already 
processed. 
 
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 93970-26 is Duplex scan of extremity veins including 
responses to compression and other maneuvers. 
 
We find that CPT code 93970-26 is not supported in the medical record. Specifically, the submitted 
documentation supports 1 (one) unit of 93970-26, which was previously approved and paid. There is no 
additional documentation supporting an additional study which was billed. Based on this information, we 
decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided 
that the Plan does not have to pay for duplex scan of extremity veins (93970) provided May 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on October 29, 2019. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree 
with this coinsurance. 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 durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed is $663.20. The total amount you are being 
asked to pay is $132.64 ($663.20 x 20% = $132.64) for durable medical equipment. Durable medical 
equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on October 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection (20610) provided. 
 
You asked the Plan to waive the copayment for an injection. You say that this should not be considered 
surgery. The Plan denied your request. The Plan says this 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 $250 
copayment for outpatient surgery services.  
 
You have been asked to pay a $246.45 copayment for an injection because the allowed amount is less than your 
contractual copayment. An injection falls within the outpatient surgery 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 an injection (20610) provided.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 6, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the hospital should be 
responsible for this charge because you were turned away from your destination. The Plan denied your request. 
The Plan says you were charged this cost sharing 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 $125 
copayment for each ambulance trip. You had an ambulance trip on this date of service. The Plan charged you 
$125 for these services. 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 ambulance services provided on 
March 6, 2020.