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

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on September 
26, 2019. 
 
You asked the Plan to pay for the dental service. You say that you noticed that your claim which had been paid 
by the Dental Plan was submitted under the wrong provider initially. You say that you called the Dental Plan 
and asked them to resubmit it with the correct dentist. You say that now the Dental Plan has reversed the claim 
and is requesting the overpayment of $110 be remitted to them. You also say that you have had previous 
services performed by this dentist that have been paid for so you do not understand why you need to return the 
$110. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The 
Plan says that services performed by a provider who has opted out of Medicare are not payable. The Plan also 
says that you are responsible for this service. 
 
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 
the periodic oral evaluation (D0120) provided on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transitional care management (TCM) services provided
on September 16, 2019.
You asked the Plan to pay for the TCM services. You say that this should be covered. The Plan denied your
request. The Plan says this was a telehealth service and must be reported with POS code 02.
The Plan must follow Medicare rules. Medicare rules say that TCM services are payable to a provider to
oversee a patient after discharge when the discharge location is a non-skilled setting.
In this case, the POS code used was 31 for skilled nursing facility (SNF). TCM services are not payable for
patients discharged to a SNF. Therefore, we decided that the Plan does not have to pay for the transitional care
management (TCM) services provided on September 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the full amount for the extraction (D7210) of teeth # 22, 
25, 26, 28 and 31 provided on March 31, 2020. 
 
You asked the Plan to reimburse the full amount for the dental services. You say that you sent this claim in for 
reimbursement. You say that you received a denial of payment. You say that this is incorrect because you 
asked for reimbursement and not payment. You also say that you wish to have a letter stating that the letter you 
received is incorrect. The Plan denied your request. The Plan says there is an annual allowance of $200 for 
fillings and simple extractions. The Plan says the annual allowance was reached while processing 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 and extractions are a covered service, 
the annual allowance for this service has been exceeded. The record shows that the Plan paid $135 for the 
extraction of tooth # 22 and $65 towards the extraction of tooth # 25, totaling $200. Therefore, we decided that 
the Plan does not have to reimburse any additional amount for the extraction (D7210) of teeth # 22, 25, 26, 28 
and 31 provided on March 31, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for two diagnostic ultrasounds provided by a 
participating provider on March 19, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that the doctor ordered these 
ultrasounds along with your annual mammography. You say that you have a family history of breast cancer. 
The Plan denied your request. The Plan says the correct copayment 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 $125 
copayment for outpatient diagnostic tests/in-network.  
 
You have been asked to pay $83.35 for each diagnostic ultrasound which is less than your copayment amount 
of $125 for a diagnostic ultrasound. The total amount you are being asked to pay is $166.70 ($83.35 x 2 
diagnostic ultrasounds = $166.70). A diagnostic ultrasound falls within the outpatient diagnostic tests/in-
network 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 two diagnostic ultrasounds 
provided by a participating provider on March 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services 
(90792) provided on March 25, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical 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 the psychiatric diagnostic evaluation with medical 
services (90792) provided on March 25, 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 esophagogastroduodenoscopy with biopsy (43239), 
saline solution infusion (J7030), propofol injection (J2704), unclassified drug injection (J3490), and the 
laboratory service (88305) rendered by the out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 provider and the facility in this case are not network providers 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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the esophagogastroduodenoscopy with biopsy (43239), saline 
solution infusion (J7030), propofol injection (J2704), unclassified drug injection (J3490), and the laboratory 
service (88305) rendered by the out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general health panel (80050) miscellaneous medicine 
services (99070) outpatient office visit (99203) domiciliary/home visit (99341) and unclassified drugs (J3490) 
provided on February 26, 2018 to February 3, 2020. 
 
You asked the Plan to pay for the non-urgent/emergent medical services. You say that any amount received as 
reimbursement will help with daily expenses. Please reconsider reimbursement of these claims. The Plan denied your request. The Plan says the services are non-emergency services and not covered. With the exception of urgent or emergent 
care, these services are not covered. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care. Medicare rules say that this PPO plan will generally cover your medical care as long as the 
care you receive is considered medically necessary and you receive your care from a provider who is eligible to 
provide services under Original Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-urgent/emergent medical services have not been met. Therefore, we decided that the Plan does not have to pay for general health panel (80050) miscellaneous medicine services (99070) outpatient office visit (99203) domiciliary/home visit (99341) and unclassified drugs (J3490) provided on February 26, 2018 to February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Puraply am (Q1496) provided on December 31, 2019. 
 
You asked the Plan to pay for the Puraply am. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted does not support 
the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code Q4196 is puraply am, per square centimeter.  
 
We find that CPT code Q4196 is not supported in the record. Specifically, the record does not clearly indicate 
that 10 units of Puraply am were provided on the billed date of service. Based on this information, we decided 
that Medicare rules for coverage of the Puraply am have not been met. Therefore, we decided that the Plan does 
not have to pay for Puraply am (Q1496) provided on December 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tenotomy, shoulder area; single tendon (CPT Code 23405 
AS-RT) provided on January 8, 2020. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
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 service. Our physician reviewer found 
the operative report does not support the procedure of open tenotomy or even tenotomy. The operative report 
describes arthroscopic tendon debridement. The code should be denied. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for tenotomy, shoulder area; single tendon (CPT Code 23405 AS-RT) provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-covered chiropractic services (98943) provided from February 5, 2020 to May 27, 2020.You asked the Plan to pay forthe non-covered chiropractic services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says CPT code 98943 is not covered when provided by a chiropractor.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 forthe non-covered chiropractic services (98943) provided from February 5, 2020 to May 27, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory testing provided on November 12, 2019. 
 
You asked the Plan to pay for the lab testing. You say that this testing was medically necessary and should be 
paid. The Plan denied your request. The Plan says that there is no signed ordered showing that the provider 
intended to order this testing. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The rules also say that plans must make reasonable and diligent efforts to gather and forward information to 
support its denial. 
 
In this case, this testing was ordered by a network provider with the Plan. The documentation submitted on 
appeal references this provider's electronic signatures for each individual test provided. It does not appear that 
the Plan requested more details order information after the date that the denial was originally appealed in June 
2020. Given that services ordered by a network provider are deemed approved by the Plan and that there is not 
clear support that these were not ordered by this provider, we find that this denial of payment is not supported. 
Therefore, we decided that the Plan has to pay for the laboratory testing provided on November 12, 2019.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network 
(OON) provider on January 13, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99214) rendered by the out of network (OON) provider on January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the metabolic panel, lipid panel, urinalysis, glycated 
hemoglobin testing, thyroid hormone testing, complete blood count, and urine culture provided on May 19, 
2020. 
 
You asked the Plan to pay for the lab testing. You say that this testing as medically necessary and should be 
paid. The Plan denied your request. The Plan says this lab testing was done in conjunction with a breast cancer 
screening. This testing 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 testing provided was not performed in relation to any signs/symptoms or reported diagnoses. The only 
reported diagnoses were encounter for general medical exam and encounter for breast cancer screening. This 
testing is not covered for breast cancer screening. Therefore, we decided that the Plan does not have to pay for 
the metabolic panel, lipid panel, urinalysis, glycated hemoglobin testing, thyroid hormone testing, complete 
blood count, and urine culture provided on May 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on March 31, 2020. 
 
You asked the Plan to pay for the psychotherapy 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 
psychotherapy 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 psychotherapy services provided on March 31, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the lower partial denture provided on March 17, 2020. 
 
You asked the Plan to pay more for the lower partial denture. You say that they did not fix your teeth. You say 
that you won't pay them until they fix your teeth. The Plan denied your request. The Plan says you have met 
your $1,000 annual maximum. 
 
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 $1,000 annual 
allowance. The Plan paid $1,000 for the dentures provided on March 17, 2020. You are responsible for the 
remaining amount. Therefore, we decided that the Plan does not have to pay more for the lower partial denture 
provided on March 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept services provided on August 16, 
2019. 
 
You asked the Plan to pay for the paramedic intercept services. You say that this was a higher level of care 
transport. 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 pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the paramedic does not have a contract with the volunteer ambulance company 
that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic 
intercept services provided on August 16, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 10, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, immediate lower denture and unspecified 
preventive procedure and sales tax provided on June 15, 2020. 
 
You asked the Plan to pay for the extractions, immediate lower denture and unspecified preventive procedure 
and sales tax. You say that you were unaware you had a preventive only policy. The Plan denied your request. 
The Plan says the services are not covered benefits. 
 
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 
extractions, immediate lower denture and unspecified preventive procedure and sales tax provided on June 15, 
2020.