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

 
We decided that the Plan does not have to pre-approve Alveoplasty (D7311). 
 
You asked the Plan to pre-approve Alveoplasty. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says Alveoplasty is not covered by Medicare or the Plan's supplemental 
dental 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 pre-approve 
Alveoplasty (D7311).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Hyaluronan injection you received on 
July 10, 2020. 
 
You asked the Plan to waive the coinsurance for the Hyaluronan injection. You say that you were told this 
injection was covered in full. The Plan denied your request. The Plan says you were charged this coinsurance 
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 Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Hyaluronan injection. The Hyaluronan injection falls 
within the Medicare Part B drugs 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 
the Hyaluronan injection you received on July 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aquatic therapy provided on September 18, 2019. 
 
You asked the Plan to pay for aquatic therapy. You say that the enrollee was pre-approved so 10 visits were 
provided. You say that the claims should be processed for payment.  The Plan denied your request. The Plan 
says the techniques used could have been applied using land based physical therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 
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 aquatic therapy. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that there was no documentation in the records that land based 
physical therapy would have been inappropriate for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pay for aquatic therapy provided on September 18, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound you had on March 19, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you should only have to pay a $10 
copayment. 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 clearly says that you must pay a $100 
copayment for radiological diagnostic services, including ultrasounds.  
 
You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the radiological 
diagnostic 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 the ultrasound you 
had on March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 
80159, and 80173 provided on May 28, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, the documentation submitted did not support that these laboratory tests were performed 
with blood sampling. Blood specimen collection is by venipuncture; however, the lab requisition states a urine 
specimen was collected; therefore, the billed services cannot be verified. Based on this information, we decided 
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 
provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 16, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physicians 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 March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound supplies coded as A4452, A6252, A6546, A6021, 
A6446, A6209and A6547 services provided on April 1, 2019 to July 8, 2019 by an out of network (OON) 
provider. 
 
You asked the Plan to pay for the wound supplies. You say that these supplies are medically necessary. Please 
review the documentation and consider authorizing these services to reprocess for payment. The Plan denied 
your request. The Plan says enrollee's must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Non-emergent services with non-contracted providers require 
prior authorization before services being rendered. 
 
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 wound supplies coded as A4452, A6252, 
A6546, A6021, A6446, A6209and A6547 services provided on April 1, 2019 to July 8, 2019 by an out of 
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this charge is incorrect. 
The Plan denied your request. The Plan says the correct copayment was 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 $285 
copayment for each day of days 1-6 of each Medicare-covered inpatient hospital admission/stay.  
 
You have been asked to pay $1,425, or a $285 copayment for each day of a 5-day inpatient hospital stay. An 
inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an inpatient hospital stay.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 18, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like this appeal reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says 
that the member's primary care physician did not refer these services. 
 
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 an office visit provided on June 18, 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 extraction (D7210) and biological dressing (D7922) 
provided on June 25, 2020. 
 
You asked the Plan to pay for the dental services. You say that you had a broken tooth. You say that you were 
in a lot of pain. You say that this should be covered because you needed it to be fixed. The Plan denied your 
request. The Plan says extractions are not listed as a covered service. The Plan says biological dressing is not 
listed as a covered service either. 
 
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. Additionally, the services you are asking the Plan to pay for involve 
the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your 
teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the 
Plan does not have to pay for the extraction (D7210) and biological dressing (D7922) provided on June 25, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 23, 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 procedure codes 80157, 80177, 80201, 80162, 80159 and 80173 are 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. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical 
record. Specifically, there is no documentation of the testing performed on blood specimens. 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 laboratory services rendered on April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on August 17, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 August 17, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 28, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that these services should be 
covered in full as the enrollee was unresponsive and taken to the nearest hospital. The Plan denied your 
request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $100 copayment for ground ambulance services.  
 
The enrollee has been asked to pay a $100 copayment for the ambulance services. This copayment applies 
regardless of the reason for the transport. 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 copayment for 
ambulance services provided on June 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on July 3, 2020. 
 
You asked the Plan to pay for the testing. You say that you would like reconsideration because this testing is 
medically necessary and required. The Plan denied your request. The Plan says this claim has been submitted 
without the appropriate CPT code to represent the service provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the code for GUARDANT360 is 81479. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, Medicare guidance indicates that the appropriate code 
for this service is CPT code 81479. Therefore, we decided that the Plan does not have to pay for Guardant360 
testing provided on July 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ultrasound services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the ultrasound services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the 
care and treatment you are requesting. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the ultrasound services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the additional services rendered during 
your annual wellness visit provided on August 25, 2020. 
 
You asked the Plan to waive the copayment for the additional services rendered during your annual wellness 
visit. You say that you were told the additional services rendered would be included under your annual 
wellness visit. The Plan denied your request. The Plan says the copayment applied correctly in this case. 
 
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 $10 
copayment for physician/practitioner services.  
 
You have been asked to pay a $10 copayment for the additional services rendered during your annual wellness 
visit. These additional services fall within the physician/practitioner 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 the additional services rendered during your annual wellness visit 
provided on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999), comprehensive oral 
evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on July 14, 2020. 
 
You asked the Plan to pay for the preventive procedure, comprehensive oral evaluation, and complete series of 
intraoral x-rays. You say that you wanted a second opinion from another provider about the services you were 
told that you needed. The Plan denied your request. The Plan says the preventive procedure is not a covered 
benefit. The Plan also says that the comprehensive oral evaluation and complete series of intraoral x-rays 
exceed the frequency limitations in 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, unspecified preventive procedure is not 
among those covered under this benefit. The Plan contract clearly states that comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan 
years. The record shows that you received a comprehensive oral evaluation and complete series of intraoral x-
rays on July 8, 2020, and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays 
(D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the 
preventive procedure (D1999), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays 
(D0210) provided on July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 2, 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 procedure codes 80157, 80177, 80201, 80162, 80159 and 80173 are 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. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical 
record. Specifically, there is no documentation of testing on blood specimens. 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 laboratory services rendered on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit you had on August 6, 2020. 
 
You asked the Plan to pay for the chiropractic office visit. You say that you feel as though these services 
should be covered. The Plan denied your request. The Plan says the office visit is not a covered benefit.  The 
Plan says that they paid for the services related to manual manipulation of the spine and applied a $15 
copayment.  However, the Plan says that the additional office visit services are not covered under your 
contract. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic office visit you had on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breath hydrogen test provided. 
 
You asked the Plan to pay for the breath hydrogen test (91065). You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says this test is not a covered benefit for this diagnosis. 
 
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. This test is not covered for the enrollee's diagnosis. Based on this 
 
 
information, we decided that Medicare rules for coverage of the breath hydrogen test (91065) have not been 
met. Therefore, we decided that the Plan does not have to pay for the breath hydrogen test provided.