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, first intraoral periapical 
x-ray, posterior resin-based composite of two surfaces, and posterior resin-based composite of four or more 
surfaces provided on December 10, 2019 by an OON provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, and resin-
based composites. You say that prior to receiving these services, you asked the provider if they accepted your 
insurance and if the services would be covered and were assured that you would be covered. You also say that 
you were not informed that the treating provider was OON. The Plan denied your request. The Plan says these 
services were rendered by an OON provider. The Plan also says that payment cannot be made for services 
provided by an OON provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation, first intraoral periapical x-ray, posterior resin-based composite of two surfaces, 
and posterior resin-based composite of four or more surfaces provided on December 10, 2019 by an OON 
provider.  
 
Your complaint about being misled and receiving flawed treatment is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation, and bitewing x-
rays provided on May 4, 2020 by an OON provider. 
 
You asked the Plan to pay for the prophylaxis, periodic oral evaluation, and bitewing x-rays. You say that you 
say that you made several calls to see if you would be covered for services provided by your current dentist, 
and were advised they would be covered. The Plan denied your request. The Plan says these services were 
rendered by a non-contracted provider. The Plan also says that no benefits are available for procedures 
performed by OON providers. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
prophylaxis, periodic oral evaluation, and bitewing x-rays provided on May 4, 2020 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Thyrotropin injections you received on 
May 11, 2020 and May 12, 2020. 
 
You asked the Plan to waive the coinsurance for the Thyrotropin injections. You say that you had these 
injections three years ago and they didn't cost this much. 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B drugs that are administered by a provider.  
 
You have been asked to pay 20% coinsurance for the Thyrotropin injections. You received these Part B drug 
injections in your doctor?s office, so the 20% coinsurance is applicable. For each date of service, the allowable 
amount for this drug is $1700.91. The coinsurance obligation for each date is $340.18 ($1700.91 x 20% = 
$340.18), for a total of $680.36 ($340.18 x 2 = $680.36). This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for the Thyrotropin injections you received on May 11, 2020 and May 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) and orthotics (L0650, 
L1851, L1971, L3170, L3916, L3960) provided on March 24, 2020. 
 
You asked the Plan to pay for a neuromuscular stimulator and orthotics. You say that these items are supported 
by the records. The Plan denied your request. The Plan says there is not a valid proof of delivery for these 
items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. As a general Medicare rule, the date of service shall be the date of 
delivery. 
 
The record does not contain a valid proof of delivery for the supplies provided in this case. While there are 
multiple delivery tickets and invoices in the file, none of them show a delivery or shipping date that matches 
the date of service. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for a neuromuscular 
stimulator (E0745) and orthotics (L0650, L1851, L1971, L3170, L3916, L3960) provided on March 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace provided with billed date of service May 4, 
2020. 
 
You asked the Plan to pay for the back brace. You say that this was clearly provided for a covered indication 
and should be reimbursed. The Plan denied your request. The Plan says there is no documentation in the record 
showing this was provided for a valid condition. 
 
The Plan must follow Medicare rules. Medicare rules say that the billed date of service should never be prior to 
the date of delivery for durable medical equipment.  
 
In this case, the documentation shows that this brace was packaged for delivery on May 15, 2020 and was 
delivered on May 22, 2020. There is no justification provided for the billed date of service of May 4, 2020. 
Therefore, we decided that the Plan does not have to pay for the back brace provided with billed date of service 
May 4, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit (99282) 
provided on February 12, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $90 
copayment for Medicare-covered emergency room visits.  
 
You have been asked to pay a $90 copayment for the emergency room service provided. 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 emergency department visit (99282) provided on February 12, 
2020.  
 
Your complaint about the care you received in the emergency room is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered on December 11, 2019. 
 
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 procedure code 37765 is not supported. 
 
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 37765 is stab phlebectomy of varicose veins, 1 extremity; 
10-20 stab incisions. 
 
We find that CPT code 37765 is not supported in the medical record. Specifically, there is no documentation of 
stab phlebectomy of the varicose veins of one extremity, for 10-20 incisions. Based on this information, we 
decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the 
Plan does not have to pay for the services rendered on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy of a molar tooth (D3330), occlusal 
adjustment (D9951), endodontic therapy of a premolar tooth (D3320), and apexification/recalcification 
(D3352) provided on May 5, 2020 and May 20, 2020. 
 
You asked the Plan to pay for the endodontic therapies, occlusal adjustment, and apexification/recalcification. 
You say that the root canals were provided in order to avoid having to have a complete bridge replacement and 
stop the infection. You also say that you believe these services should fall under minor restoration, which is 
covered at 100%. 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 
endodontic therapy of a molar tooth (D3330), occlusal adjustment (D9951), endodontic therapy of a premolar 
tooth (D3320), and apexification/recalcification (D3352) provided on May 5, 2020 and May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 16, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 panel rendered on April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided to the enrollee from September 20, 
2019, to September 22, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The services in question were billed with an inpatient place of service 
code. However, the records show that the enrollee was not under inpatient status during this episode of care. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee from 
September 20, 2019, to September 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 2, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 orthosis. Our reviewer says that the 
enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the available 
documentation in the case file does not support that the requested lumbar-sacral orthosis was medically 
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the 
LCD. An appropriate history and a physical examination of the back would reasonably be required to 
adequately assess whether the coverage criteria for an LSO have been met. The documentation does not 
support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as 
there is no documentation of a physical examination of the back. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on April 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing 
provided to the enrollee on February 20, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health 
of the patient are not a benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that the molecular genetic hereditary predictive screening testing provided to 
the enrollee on February 20, 2020 was not medically reasonable or necessary. Molecular genetic hereditary 
predictive screening testing is not a Medicare benefit for the diagnosis as listed on the claim and are done for 
screening purposes. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on February 20, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code A0425 provided on August 7, 2019. 
 
You asked the Plan to pay for CPT code A0425. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 will be denied. 
 
In this case, the MUE for CPT code A0425 is 250. You billed 280 units of this code, exceeding the MUE. 
Based on this information, we decided that Medicare rules for coverage of CPT code A0425 have not been met. 
Therefore, we decided that the Plan does not have to pay for CPT code A0425 provided on August 7, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the Mohs surgery you had at your doctor's office on 
May 26, 2020. 
 
You asked the Plan to waive the copayment for the Mohs surgery. You say that this was not an elective or 
cosmetic procedure, so it should be paid for. The Plan denied your request. The Plan says that you were 
charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms 
how much you should expect to pay for outpatient surgery performed in a doctor's office.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $275 
copayment for outpatient surgery performed in a doctor's office. The Plan contract does not clearly say how 
much enrollees must pay for outpatient surgery performed in a doctor's office.   Under the Outpatient Surgery 
section of your Evidence of Coverage (EOC), the Plan writes that you have a $0-$275 copayment for 
outpatient surgery services furnished in a physicians office.  In addition, the EOC says that a$0 copayment 
for outpatient surgery applies to minor procedures furnished in a physicians office.  
 
Based on our review, it is not clear from the language of the EOC when $0 would apply to such outpatient 
surgery services vs. when a $275 copayment would apply.  There is nothing in the section explaining this.  In 
addition, there is nothing in the outpatient surgery section of the EOC that defines what is considered a minor 
procedure.  Without such definition or explanation, it is not reasonable for the Plan to expect you to know 
when $0 applies vs. when $275 applies to outpatient surgical services in a physicians office. Therefore, we 
decided that the Plan has to waive the copayment for the Mohs surgery you had at your doctor's office on May 
26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings x-rays (D0274) provided on May 15, 2020. 
 
You asked the Plan to pay for bitewings x-rays (D0274). You say that any office you have used in the past 15 
years does not do a panoramic x-ray. You say that these x-rays have always been paid for once a year by 
insurance. The Plan denied your request. The Plan says the 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. Therefore, we decided that the Plan does not have to pay for bitewings 
x-rays (D0274) provided on May 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray (D0220) and extraction (D7210) provided 
on May 12, 2020. 
 
You asked the Plan to pay for the intraoral x-ray (D0220) and extraction (D7210). You say that the brochure 
specifically states extraction of an erupted tooth is covered. 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 
intraoral x-ray (D0220) and extraction (D7210) provided on May 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on 
March 10, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says the services are not supported in the medical records received. 
 
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 orthosis. Our reviewer says that the 
enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the available 
documentation in the case file does not support that the requested lumbar-sacral orthosis was medically 
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the 
LCD. The documentation does not support that the lumbar-sacral orthosis was ordered for one of the following 
indications: to reduce pain by restricting mobility of the trunk, to facilitate healing following an injury to the 
spine or related soft tissues, to facilitate healing following a surgical procedure on the spine or related soft 
tissue, or to otherwise support weak spinal muscles and/or a deformed spine. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on March 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided from November 6, 2018 to 
November 22, 2018. 
 
You asked the Plan to pay for the services provided. You say that it took time to get new receipts and doctor's 
orders. The Plan denied your request. The Plan says the claim was submitted after timely filing limitations. 
 
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 services provided was not filed until April 13, 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 medical services provided from November 6, 2018 to 
November 22, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on January 28, 2020. 
 
You asked the Plan to pay for the wound care services. The Plan denied your request. The Plan says the wound 
care visits were for services that were foreseen, not urgent or emergent, available in area and not prior 
authorized. 
 
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 
wound care 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 wound care services provided on January 28, 2020.