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

We decided that the Plan does not have to pay for the oral exam (D0120), the cleaning (D1110), the crown 
(D2740), and the filling (D2393) provided on August 10, 2020. 
 
You asked the Plan to pay for the dental services. You say that your tooth broke completely leaving an empty 
space with the adjoining tooth filling becoming loose and needed to be refilled. You say that your plan does not 
cover crowns. You say that your plan does cover emergency treatment, which this was. You also say that it 
covers 100% for fillings. The Plan denied your request. The Plan says oral exams and cleanings are covered 
once per year. The Plan says that these frequency limits have been exceeded. The Plan also says crowns and 
fillings are not covered services. 
 
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 frequency limit of 1 oral exam and 
1 cleaning per year have been exceeded. The record shows that the Plan paid for these services that you 
received on January 28, 2020. Additionally, the crown and filling are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), the cleaning 
(D1110), the crown (D2740), and the filling (D2393) provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on October 25, 2019 by an 
out of network provider. 
 
You asked the Plan to pay for the home health services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request 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 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 health services provided on October 25, 
2019 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy administration rendered on January 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 procedure code 96413 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 96413 is chemotherapy administration, intravenous 
infusion technique; up to 1 hour, single or initial substance/drug. 
 
We find that CPT code 96413 is not supported in the medical record. Specifically, there is no documentation of 
chemotherapy administration via IV infusion for up to one hour. 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 chemotherapy administration rendered on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bath tub and toilet rail provided on January 29, 2020. 
 
You asked the Plan to pay for the provided services. You say that you cannot pick yourself up if you fall. The 
Plan denied your request. The Plan says the items are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for the bath tub and toilet rail provided on January 29, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5257) provided on June 8, 2020 by an 
out-of-network OON provider. 
 
You asked the Plan to pay for the hearing aids. You say that you want the cost share to be processed at the in-
network level. The Plan denied your request. The Plan says the cost share applied correctly in this case and that 
there are in-network options available to purchase hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan covers 
hearing aids purchased OON with a cost sharing guideline of 25% coinsurance, then any amount over $1,000 
every 3 years.  
 
We looked at the file and the Plan's rules. The provider charged $3,295. You were left with a total cost share 
amount of $2,545 including the 25% coinsurance of $250. Based on this information, we decided that the Plan's 
processed the cost share for hearing aids correctly. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5257) provided on June 8, 2020 by an out-of-network OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee. 
 
You asked the Plan to pay for home health services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not billed with the correct type of bill code. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, type of bill 
 
 
323 is not a valid type of bill for these services. Therefore, we decided that the Plan does not have to pay for 
the home health services provided to the enrollee.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided July 29, 2019. 
 
You asked the Plan to pay for the lab services. You say that these services should be covered. The Plan denied 
your request. The Plan says that the services are non-covered because they do not meet the criteria outlined in 
Medicare Local Coverage Determinations. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the plan did not provide the IRE with sufficient documentation to 
support the denial. The only documentation provided by the plan was an appeal decision letter and screen 
captures from the plan's computer system. The plan did not provide a copy of the Notice of Denial of Payment 
or any clinical documentation. Without this information, the IRE cannot determine if the services at issue meet 
the criteria outlined in the Local Coverage Determinations cited by the plan. Therefore, we decided that the 
Plan has to pay for lab services provided July 29, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on July 7, 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 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 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 
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 July 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered from January 10, 2020 to 
January 22, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The services at issue are laboratory services related to ESRD. 
Payment is included with the payment to the ESRD facility. Therefore, we decided that the Plan does not have 
to pay for the laboratory services rendered from January 10, 2020 to January 22, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided out of network. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. 
The Plan has network providers available who can provide the 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 outpatient mental health care 
provided out of network.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost for the office visit, EKG and echocardiography 
provided on November 4, 2019. 
 
You asked the Plan to reduce the cost for the office visit, EKG and echocardiography. The Plan denied your 
request. The Plan says the copayments applied 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 $5 
copayment for services obtained from an in-network primary care provider and a $20 copayment for Medicare-
covered non-radiological and radiological diagnostic services.  
 
You have been asked to pay a total of $25 for the office visit, EKG and echocardiography.  
 
Service Allowed Amount Standard Copayment Member Liability 
office visit $85.50 $5 $5 
EKG and Echocardiography $246.88 $20 $20 
Total:   $25 
 
The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit 
category. The EKG and echocardiography fall within the "Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies" 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 reduce the cost for the office visit, 
EKG and echocardiography provided on November 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on August 6, 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 code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 32557. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 32557. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on August 6, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from January 
20, 2020 to January 31, 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 the enrollee was in a federal hospice program at the time the services were rendered. 
 
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 home health services provided to the enrollee from January 
20, 2020 to January 31, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing and aide services provided to the enrollee from 
March 16, 2020 to March 31, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says due to the enrollee's hospice election at the time of service, these claims 
need to be addressed by Original Medicare. 
 
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 
nursing and aide services provided to the enrollee from March 16, 2020 to March 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the eye exam provided on March 3, 2020. 
 
You asked the Plan to waive the copay for the eye exam. You say that you should not be responsible for the 
cost share. The Plan denied your request. The Plan says that this was billed as a medical service not a routine 
exam. 
 
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 $40 
copay for each Medicare-covered eye exam service.  
 
You have been asked to pay a $40 copay for the eye exam. The eye exam falls within the Medicare-covered 
eye exam service 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 copay for the eye exam provided on 
March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the extraction (D7210) provided. 
 
You asked the Plan to reimburse you for the dental service. You say that you paid $257 for the extraction and 
x-rays. You say that it should have only been a $120 copayment. You say that you had a cleaning for your 
upper and lower teeth and paid $454. You say that you should not have had to pay anything according to your 
plan. The Plan denied your request. The Plan says the extraction is not listed as a covered service. 
 
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 extraction is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the 
extraction (D7210) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided. 
 
You asked the Plan to waive the copayment for the office visit. You say that you couldn't follow-up within 90 
days due to the pandemic. You say that you shouldn't have a copayment. The Plan denied your request. The 
Plan says the copayment applied 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 $50 
copayment per visit for a specialist office visit.  
 
You have been asked to pay $44.31, which is less than the standard $50 copayment for the office visit. The 
office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. 
The office visit was provided after the covered 90-day follow-up period. 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 office visit provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on June 3, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says while a portion of this claim was paid, the denied claims have invalid POS codes. 
 
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 claim submitted cannot be paid 
due to errors with the POS code.  Medicare coverage criteria are not met. Therefore, we decided that the Plan 
does not have to pay for lab services provided to the enrollee on June 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator (E0745) provided on June 12, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says he reasonableness of the provided 
durable medical equipment is not established. 
 
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.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the record does not indicate the completion of a 
physical examination. Of note, the Plan states that this provider is known for utilizing unsolicited telephonic 
consult to obtain clinical information. Therefore, we decided that the Plan does not have to pay for the 
neuromuscular stimulator (E0745) provided on June 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on June 26, 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 code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 32557. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 32557. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment that you provided from February 17, 
2020 through February 26, 2020. 
 
You asked the Plan to pay for the chiropractic treatment. The Plan denied your request. The Plan says the 
enrollee must receive care from a network provider. In most cases, care received from an out-of-network 
provider will not be covered. 
 
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 
chiropractic treatment. 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 chiropractic treatment that you provided from February 17, 
2020 through February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87481, 87500, 87641, 87652, 87653, 87798, & 
87900) provided March 25, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 87481, 87500, 87641, 87652, 87653, 87798, & 87900 is not supported in the medical 
record. Specifically, the documentation provided does not provide lab reports or results for the procedures 
billed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been 
met. Therefore, we decided that the Plan does not have to pay for lab services (87481, 87500, 87641, 87652, 
87653, 87798, & 87900) provided March 25, 2020.