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

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral 
periapical x-ray, periodontal maintenance, and drugs or medicaments dispensed in the office for home use 
provided on June 18, 2020. 
 
You asked the Plan to pay for the intraoral periapical x-rays, periodontal maintenance, and drugs or 
medicaments. You say that you were only expecting a normal cleaning, x-rays, and normal examination. 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 first 
intraoral periapical x-ray, additional intraoral periapical x-ray, periodontal maintenance, and drugs or 
medicaments dispensed in the office for home use provided on June 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the provided subcutaneous hormone pellet implantation 
provided on June 4, 2020 
 
You asked the Plan to pay for the provided subcutaneous hormone pellet implantation. You say that the 
provided subcutaneous hormone pellet implantation provided on June 4, 2020 was medically necessary. The 
Plan denied your request. The Plan says the provided subcutaneous hormone pellet implantation provided on 
June 4, 2020 was not medically necessary. 
 
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 provided subcutaneous hormone pellet 
implantation. Our reviewer says that the provided subcutaneous hormone pellet implantation provided on June 
4, 2020 was not medically necessary. Our physician reviewer found there is no documentation that the enrollee 
has been treated with currently available FDA-approved estrogen and testosterone products for her symptoms 
and has failed these products.  According to the Global Consensus Position Statement on the Use of 
Testosterone Therapy for Women (JCEM October 2019), the only indication for testosterone therapy in 
postmenopausal women is the treatment of female sexual dysfunction, specifically hypoactive sexual desire 
disorder and female sexual arousal disorder.  The Global Consensus Position Statement specifically states that 
for this treatment, testosterone levels should be maintained in at the normal female premenopausal range, and 
they do not endorse pellet therapy as these products are compounded and often produce testosterone levels in 
supraphysiologic doses.  Therefore, the pellet form of these medications are not medically necessary and 
reasonable for the enrollee as alternative products exist and it is unclear that the enrollee has been formally 
evaluated for female sexual dysfunction. 
 
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 provided subcutaneous hormone pellet implantation have not been met. 
Therefore, we decided that the Plan does not have to pay for the provided subcutaneous hormone pellet 
implantation provided on June 4, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services (97110, 97140, G0283) 
provided, by an out of network (OON) provider. 
 
You asked the Plan to pay for the physical therapy services. 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 physical therapy services (97110, 97140, 
G0283) provided, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (CPT 99232) provided to the 
enrollee on June 9, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says physicians will only be reimbursed for one hospital visit per day for the same patient, whether 
the problems seen during the encounters are related or not. 
 
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 99232 is "Subsequent hospital care, per day, for the 
evaluation and management of a patient." 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, there is already a claim for 
the same date of service by a physician in the same group with the same specialty. 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 subsequent hospital care (CPT 99232) provided to the enrollee on June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the allergy injection (95115) provided on July 20, 2020, by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the allergy injection. 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 allergy injection (95115) provided on July 20, 
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 23, 2020 and 
billed under codes 80157, 80201, 80162, 80159 and 80173. 
 
You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says the documentation submitted did not support that the codes denied 
were performed with blood sampling.  Blood specimen collection is by venipuncture; however, the lab 
requisition does not state the specimen collected for the billed codes; therefore, the billed service cannot be 
verified. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT codes. In this case, the claim submitted cannot be paid 
due to a discrepancy regarding the type of specimen collected. Medicare billing criteria were not met. 
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on March 23, 
2020 and billed under codes 80157, 80201, 80162, 80159 and 80173.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiological services (70491, 70487) provided, by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the radiological services. 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 radiological services (70491, 70487) provided, 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bone replacement graft for ridge preservation provided on June 17, 2020.You asked the Plan to pay forthe bone replacement graft. You say that the Plan advised that you could go to this dental office. You also say that you paid $500, but said your insurance would pay for the services.The Plan denied your request. The Plan says bone graft is not a covered service under your dental plan. The Plan also says that you signed an authorization for the bone graft stating you understood that your insurance may not pay for it.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 forthe bone replacement graft for ridge preservation provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical extractions (D7210) provided from June 17, 2020, to July 6, 2020.You asked the Plan to pay forthe dental services. You say that you had dental deterioration due to radiation. You say that you need heart surgery. You say that you need your teeth removed before you can have the heart surgery. You also say that you were under the impression the referral from your primary care provider would take care of getting the visit covered.The Plan denied your request. The Plan says the services you received are dental in nature. The Plan also says that extractions are not a covered service.Medicare generally does not cover dental services. The Plan follows the same rule.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 forthe surgical extractions (D7210) provided from June 17, 2020, to July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of skin growth (17000) provided on March 5, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the destruction of skin growth. 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 destruction of skin growth (17000) provided 
on March 5, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon 
services are not necessary for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
15931. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the assistant surgeon services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit for new patient (99345), diabetes outpatient 
self-management training services (G0108) and discharge medications reconciled with current medication list 
(1111F) provided by an out of network (OON) provider. 
 
You asked the Plan to pay for home visit, diabetes self-management training and medications. You say that 
prior authorization is not required for telemedicine. 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 home visit for new patient (99345), diabetes 
outpatient self-management training services (G0108) and discharge medications reconciled with current 
medication list (1111F) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for preventative vaccines provided on August 7, 2020. 
 
You asked the Plan to pay for preventative vaccines under Medicare Part B. You say that these vaccines should 
be covered by the Plan. The Plan denied your request. The Plan says preventative vaccines must be submitted 
to Medicare Part D. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide preventative 
vaccines under Medicare Part B. The Plan follows the same rules. The records do not show that you have been 
injured or directly exposed to any illness related to preventative vaccines under Medicare Part B. Therefore, we 
decided that the Plan does not have to pay for preventative vaccines provided on August 7, 2020.  
 
Benefits for preventative vaccines may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient assisted living visit (99334) provided 
on June 6, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient assisted living visit. 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 established patient assisted living visit (99334) 
provided on June 6, 2020, by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the diagnostic radiology services provided 
on July 10, 2020 and July 14, 2020 and the specialist visit provided on July 10, 2020. 
 
You asked the Plan to waive the copayments for the diagnostic radiology services and the specialist visit. You 
say that you feel you should not be responsible for this cost share amount and you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says you received diagnostic radiology 
services on July 10, 2020 and July 14, 2020 and a specialist visit on July 10, 2020. The Plan says the correct 
copayments have applied per your contract with the Plan. 
 
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 $375 
copayment for Outpatient diagnostic tests and a $40 copayment for specialist visits.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received diagnostic 
radiology services on July 10, 2020 and July 14, 2020. You have been asked to pay a $108.05 copayment for 
the diagnostic radiology services provided on July 10, 2020 and a $53.03 copayment for the diagnostic 
radiology services provided on July 14, 2020, which is less than the $375 copayment for each date of service. 
The diagnostic radiology services fall within the Outpatient diagnostic tests benefit category. The file also 
shows that you received specialist services on July 10, 2020. You have been asked to pay a $40 copayment for 
the specialist visit. The specialist visit falls within the Physician/Practitioner services benefit category. This 
means that you have been asked to pay the correct amounts 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 copayments for the diagnostic radiology services provided on July 10, 2020 
and July 14, 2020 and the specialist visit provided on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and presumptive drug test (80307) 
provided on February 7, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit and drug tests. 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 office visit (99214) and presumptive drug test 
(80307) provided on February 7, 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 crowns (D2740) for teeth # 5 and 29 provided on May 
11, 2020. 
 
You asked the Plan to pay for the crowns for teeth # 4 and 5. You say that you received a letter from the plan 
that states that root canals and crowns are covered. You also say that your dentist received confirmation from 
the plan that crowns are covered. The Plan denied your request. The Plan says new crowns are not listed as a 
covered service. The Plan also says that any services not specifically identified 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 crowns you received are not among 
those covered under this benefit. The Evidence of Coverage states that recementation of existing inlays, 
crowns, implants and bridges are covered, however, new crowns are not listed as a covered service. Therefore, 
we decided that the Plan does not have to pay for the crowns (D2740) for teeth # 5 and 29 provided on May 11, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services provided on 
March 9, 2020. 
 
You asked the Plan to waive the copayment for the outpatient hospital services. You say that you feel the bill is 
incorrect. The Plan denied your request. The Plan says your previous claims were billed as physician services 
with no copayment. 
 
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 $150 
copayment for Outpatient Hospital Services.  
 
You have been asked to pay a $150 copayment for the outpatient hospital services. The outpatient hospital 
service falls 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 the outpatient hospital services provided on March 9, 2020.