Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Emergency Room Services (99283) provided February 4, 
2020. 
 
You asked the Plan to pay for the Emergency Room Services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says code 99283 shares a bundled relationship with a code 
already paid. 
 
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, we have confirmed that code 99283 
has a Column I / Column II relationship with code 99284 and cannot be paid as billed. This code cannot be 
paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for Emergency Room Services (99283) provided 
February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for therapeutic radiology provided on January 
27, 2020. 
 
You asked the Plan to waive the coinsurance for therapeutic radiology. You say that you feel that you should 
only owe a $50 copayment. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
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 therapeutic radiology. 
 
You received therapeutic radiology on January 27, 2020. The total allowed amount is $300.21 and 20% of that 
is $60.14. 
 
You have been asked to pay the total coinsurance amount of $60.14 for therapeutic radiology. Therapeutic 
radiology falls 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 waive the coinsurance for therapeutic radiology provided on January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray, crown, and core buildup, 
including any pins when required provided on January 21, 2020 by an OON provider. 
 
You asked the Plan to pay for the first intraoral periapical x-ray, crown, and core buildup. You say that the 
enrollee received an annual notice of changes that does not say anything about confirming that the enrollee's 
dentist is still in-network. You also say that the enrollee did not receive any information on what dentists are in 
network, and assumed the Plan would cover the enrollee. The Plan denied your request. The Plan says these 
services were rendered by an OON provider. The Plan also says that services done by an OON dentist 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the first 
intraoral periapical x-ray, crown, and core buildup, including any pins when required provided on January 21, 
2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 3, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the member sought non-emergent/urgent services on their own with a non-
contracted provider and did not allow the primary care physician (PCP) to request approval from the Health 
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 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 medical services provided on October 3, 2019 
by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on May 4, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that your ARNP/Mental health physician 
rendered medical care for the patients in the facility as requested by the facility. The Plan denied your request. 
The Plan says enrollee's must receive their medical services from an in-network provider. Non-emergent 
services with non-contracted providers require prior-authorization prior to 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 psychotherapy services (90837) provided on 
May 4, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network 
(OON) provider on November 4, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99214) rendered by the out of network (OON) provider on November 4, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the federally qualified health center visit (G0470) and the 
psychotherapy (90834) rendered by the out of network (OON) provider on March 19, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 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 federally qualified health center visit (G0470) and the psychotherapy (90834) 
rendered by the out of network (OON) provider on March 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation, adjunctive 
pre-diagnostic test, first intraoral periapical x-ray, and each additional intraoral periapical x-ray provided on 
May 4, 2020. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation, adjunctive pre-diagnostic test, 
and intraoral periapical x-rays. You say that these services were provided on an emergency basis because you 
were in extreme pain. You also say that you are on a fixed income. 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 bone 
replacement graft for ridge preservation, adjunctive pre-diagnostic test, first intraoral periapical x-ray, and each 
additional intraoral periapical x-ray provided on May 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam (92014) provided January 10, 2020. 
 
You asked the Plan to pay for the eye exam. You say that these services should be covered. The Plan denied 
your request. The Plan says the enrollee's benefit for eye exams has been exhausted during the benefit period at 
issue. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one eye exam annually. 
 
We looked at the file and the Plan's rules. The plan?s records show an eye exam was already provided on 
January 2, 2020. This exhausted the annual benefit. Based on this information, we decided that the Plan's rules 
for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for 
an eye exam (92014) provided January 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on 
February 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 the diagnosis is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of peritoneal 
carcinoma. A PET scan was performed for initial treatment strategy on February 6, 2020. There are no records 
provided indicating a rationale for a subsequent PET scan. The services were not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 positron emission tomography (PET) scan rendered on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation and panoramic 
x-ray provided on June 2, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that 
you were not aware that the x-ray provided was not covered by your plan. You also say that the visit was 
denied as well, and you believe both the visit and x-ray should be covered. 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 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 
problem focused limited oral evaluation and panoramic x-ray provided on June 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings (D0274) and scaling in presence of generalized 
moderate or severe gingival inflammation (D4346) provided on March 9, 2020. 
 
You asked the Plan to pay for the bitewings and scaling. You say that you believe you were billed incorrectly 
for your yearly cleaning. The Plan denied your request. The Plan says these services are not covered by the 
Plan. The Plan also says that you have not elected to purchase an optional supplemental 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 
bitewings (D0274) and scaling in presence of generalized moderate or severe gingival inflammation (D4346) 
provided on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) provided on 
April 21, 2020 and retreatment of previous root canal therapy (D3347) provided on May 5, 2020. 
 
You asked the Plan to pay for the treatment of root canal obstruction (D3331) and retreatment of previous root 
canal therapy (D3347). You say that you did not know the visits weren't covered. You say that you need help 
with the bill. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
treatment of root canal obstruction (D3331) provided on April 21, 2020 and retreatment of previous root canal 
therapy (D3347) provided on May 5, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 18, 2020 to 
March 23, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 18, 2020 to March 23, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 20, 2020 to 
March 27, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that you were only given a one day notice 
that the enrollee's skilled nursing coverage would be stopped. The Plan denied your request. The Plan says the 
criteria for continued SNF care was not met. The Plan also says that the enrollee and you were notified timely 
that the enrollee's skilled nursing services would end on March 18, 2020. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 20, 2020 to March 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on April 22, 2019. 
 
You asked the Plan to pay for the drug testing. 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. 
 
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation 
submitted did not include a physician order/lab requisition form or medical records stating exactly what tests 
were to be performed. The submitted laboratory requisition indicates that a "23490 UDS Drug Abuse" Panel 
was requested. The submitted documentation does not itemize what tests are included in this panel. Based on 
this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing coded G0483 provided on April 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 27, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing services provided on May 21, 
2020. 
 
You asked the Plan to waive the copayment for hearing services. You say that there was a sign in the providers 
office saying the test was free. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
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 $30 
copayment for hearing services.  
 
You have been asked to pay a $30 copayment for hearing services. Hearing services fall within the hearing 
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 hearing services provided 
on May 21, 2020.