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

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on June 23, 2020. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. 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. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation (D0180) provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) provided on 
September 19, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. 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 psychiatric diagnostic evaluation (90792) 
provided on September 19, 2019, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and core buildup, including any pins when 
required provided on May 5, 2020. 
 
You asked the Plan to pay for the crown and core buildup. You say that you received documentation saying 
these services were covered. You also say that your provider was advised these services were covered as well. 
The Plan denied your request. The Plan says these services are 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. The contract specifically says that only the recementation of existing 
inlays, crowns, implants and bridges are covered. Therefore, we decided that the Plan does not have to pay for 
the crown and core buildup, including any pins when required provided on May 5, 2020.  
 
Your complaint about being given conflicting information 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital surgery services 
provided on July 24, 2020. 
 
You asked the Plan to waive the copayment for outpatient hospital surgery services. You say that you had the 
procedure twice so you should only have one copayment. The Plan denied your request. The Plan says you had 
a different procedure on a different day so 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 clearly says that you must pay a $200 
copayment for Outpatient Hospital Services.  
 
You have been asked to pay a $200 copayment for outpatient hospital surgery services. The outpatient hospital 
surgery services fall within the Outpatient Hospital 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 outpatient hospital surgery services provided on July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Budesonide and Arformoterol provided 
from April 9, 2020, through July 27, 2020. 
 
You asked the Plan to waive the coinsurance for the medication. You say that the cost should be covered in full 
like it was in 2018 The Plan denied your request. The Plan says the claims were processed accordingly with 
your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that the enrollee received Budesonide and Arformoterol provided from April 9, 2020, 
through July 27, 2020. The enrollee is asked to pay 20% coinsurance per medication, per date of service. The 
enrollee's EOC states that enrollees must pay 20% coinsurance for each Medicare-covered Part B drug. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the coinsurance for Budesonide and Arformoterol provided from April 9, 
2020, through July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility discharge (99316) provided on June 26, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility discharge. You say that the services rendered 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 nursing facility discharge (99316) provided on 
June 26, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 30, 2020 and 
billed under code G0483. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan the documentation submitted did not include a physician order/lab requisition or medical 
records stating exactly what tests are to be performed. The submitted Laboratory Requisition indicates that a 
Pain Panel was requested.  The submitted documentation does not itemize what tests are included in this panel; 
therefore, the billed code cannot be verified. Of note, additional tests ordered does not specify that definitive 
testing was ordered on specified drug classes. In addition, the submitted order was partially illegible and poorly 
scanned. It is noted multiple attempts were made to obtain additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provide medical records that support the services 
billed. In this case, the claim submitted cannot be paid as billed due to inconsistency with the records provided.  
Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services provided to the enrollee on March 30, 2020 and billed under code G0483.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies, needle electromyography and 
neurological procedure provided on January 6, 2020. 
 
You asked the Plan to pay for the nerve conduction studies, needle electromyography and neurological 
procedure (95909, 95885, 95999). You say that the Plan should pay this claim. The Plan denied your request. 
The Plan says the procedures are not supported by the submitted documents. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The services are not substantiated in the records submitted. Based on 
this information, we decided that Medicare rules for coverage of the nerve conduction studies, needle 
electromyography and neurological procedure (95909, 95885, 95999) have not been met. Therefore, we 
decided that the Plan does not have to pay for the nerve conduction studies, needle electromyography and 
neurological procedure provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biologic materials to aid in soft and osseous tissue 
regeneration provided on January 7, 2020. 
 
You asked the Plan to pay for the biologic materials. The Plan denied your request. The Plan says this service 
is not a covered benefit under your 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 
biologic materials to aid in soft and osseous tissue regeneration provided on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts and PPE provided on July 14, 2020. 
 
You asked the Plan to pay for the diagnostic casts and PPE. You say that these services should be covered 
because they are medically necessary. The Plan denied your request. The Plan says these services are not 
covered. 
 
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 
diagnostic casts and PPE provided on July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator provided on September 8, 2018. 
 
You asked the Plan to pay for the services provided. You say that the claim was printed and mailed within 
timely filing. The Plan denied your request. The Plan says the claim was received past the timely filing limit. 
 
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 was not filed until June 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 oxygen concentrator provided on September 8, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 24, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 on December 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable x-ray services rendered on June 9, 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 billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 31 for a 
skilled nursing facility (SNF); however, the file shows that the enrollee was not in a SNF for the date of service 
at issue. Therefore, we decided that the Plan does not have to pay for the portable x-ray services rendered on 
June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the power lift chair provided on May 21, 2020, by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the power lift chair. You say that this chair is an essential need. 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 power lift chair provided on May 21, 2020, by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine vision services rendered on July 8, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. The file shows 
that your routine vision benefit with the Plan ended on July 1, 2008. Therefore, we decided that the Plan does 
not have to pay for the routine vision services rendered on July 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay $816 for outpatient mental health services provided from 
September 2, 2019 to November 1, 2019 under the Medicare benefit. 
 
You asked the Plan to pay for these services. You say that the Plan should pay for these services because you 
could not get all of the records due to Covid. The Plan denied your request. The Plan says you were approved 
for 88 visits from May 1, 2019 to November 1, 2019. The Plan states you were reimbursed 47 visits under a 
claim for dates of service May 1, 2019 to June 28, 2019 and reimbursed 52 visits from July 1, 2019 to August 
21, 2019. This is a total of 99 visits. In addition, it was discovered during a phone call with the provider that 
they do not accept Medicare, that they are only self-pay and that they only accept Medicaid. Finally, 
the Plan notes the information submitted for reimbursement does not contain the required codes for payment. 
 
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 a provider who does not accept Medicare payment. This provider has 
opted out of the Medicare program. It was confirmed that you entered a financial contract with this provider by 
using their self-pay option for treatment. Therefore, we decided that the Plan does not have to pay $816 for 
outpatient mental health services provided from September 2, 2019 to November 1, 2019 under the Medicare 
benefit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87486, 87498, 87500, 87532, 87541, 
87581, 87633, 87640, and 87641) provided on March 24, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you rendered medically necessary services sent 
to you by another provider. 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 laboratory services (87486, 87498, 87500, 
87532, 87541, 87581, 87633, 87640, and 87641) provided on March 24, 2020 by an out of network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services you had on July 1, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that of the 24 items being testing, 
only 9 were able to be read.  As a result, you have to have this test again.  Because of this, you don't think you 
should have to pay a copayment. The Plan denied your request. The Plan says 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 clearly says that you must pay a $15 
copayment for lab services.  
 
You have been asked to pay a $15 copayment for the lab services. This copayment applies regardless of the 
success of the test. 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 lab services you had on July 
1, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility visit (99310) provided on 
May 19, 2020. 
 
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 the Medicare hospice benefit, through fee-
for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or 
revocation. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility visit (99310) provided on May 
19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions provided on July 23, 2020. 
 
You asked the Plan to pay for the extractions. You say that your teeth had abscesses and were painful. The Plan 
denied your request. The Plan says extractions are not covered 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 
extractions provided on July 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the 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 medical services provided to you by an out-of-network provider.