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

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on April 15, 
2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that the appointment was necessary 
for a proper diagnosis and severity of your condition. The Plan denied your request. The Plan says only one 
procedure every three plan years is 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, you also have a maximum benefit of 
one comprehensive oral evaluation every three plan years. The Plan paid for a comprehensive oral evaluation 
provided on March 2, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation provided on April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 15, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. 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 services 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 these services. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on June 15, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 31267) provided on February 25, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 31267 is "Nasal/sinus endoscopy, surgical, with 
maxillary antrostomy; with removal of tissue from maxillary sinus". 
 
We asked our coding 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 services. Our reviewer says that the use 
of CPT code 31267 is not supported by the records provided. Our codingc reviewer found that the operative 
report did not include documentation of "Maxillary antrostomy, with removal of tissue from maxillary sinus." 
 
We looked at this coder's review, the file, and Medicare rules. 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 the services (CPT 31267) provided on February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on June 
2, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you cannot afford the 
charges. 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 $99 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay a $99 copayment for a diagnostic mammogram. A diagnostic mammogram 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 copayment for a diagnostic mammogram provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan services coded 93976 provided on February 
11, 2020. 
 
You asked the Plan to pay for the duplex scan 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 payable. 
 
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 95976 
for the duplex scan services have a bundled relationship with code 93975 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 the duplex scan services coded 93976 
provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a vitrectomy provided on January 30, 2020. 
 
You asked the Plan to waive the copayment for a vitrectomy. You say that you were not informed of the 
charges ahead of time. 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 $325 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You received a vitrectomy on January 30, 2020. A vitrectomy is considered an outpatient surgical procedure. 
Therefore, you are responsible to pay the $325 copayment.  
 
You have been asked to pay a $325 copayment for a vitrectomy. A vitrectomy falls within the outpatient 
surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 
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 a vitrectomy provided on 
January 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $210 copayment charged for ambulance transport 
provided on April 8, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says This copayment is a contractual obligation. 
 
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 $210 
copayment for ground ambulance transport.  
 
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 $210 copayment charged for ambulance transport provided on April 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a bladder irrigation procedure (51700) 
performed on April 3, 2020. 
 
You asked the Plan to waive the copayment for a bladder irrigation procedure. You say that this copayment is 
higher than usual. 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 $150 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.  
 
You have been asked to pay a $150 copayment for a bladder irrigation procedure. A bladder irrigation 
procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers" 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 a bladder 
irrigation procedure (51700) performed on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Haemophilus influenzae type b vaccine and the 
Meningococcal conjugate vaccine provided on November 21, 2019. 
 
You asked the Plan to pay for  the Haemophilus influenzae type b vaccine (90648) and the Meningococcal 
conjugate vaccine (90734). You say that your doctor ordered the vaccines in advance of a surgery. The Plan 
denied your request. The Plan says the vaccines are not covered under the enrollee's Medicare Part B benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Haemophilus 
influenzae type b vaccine (90648) and the Meningococcal conjugate vaccine (90734). The Plan follows the 
same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Haemophilus 
influenzae type b vaccine (90648) and the Meningococcal conjugate vaccine (90734). Therefore, we decided 
that the Plan does not have to pay for the Haemophilus influenzae type b vaccine and the Meningococcal 
conjugate vaccine provided on November 21, 2019.  
 
Benefits for  the Haemophilus influenzae type b vaccine (90648) and the Meningococcal conjugate vaccine 
(90734) 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 medical services provided on January 20, 2020 by an out 
of network (OON) provider. 
 
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 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 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 January 20, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for blood glucose test or reagent strips provided 
on April 24, 2020. 
 
You asked the Plan to waive the deductible for blood glucose test or reagent strips. You say that you have 
never paid in the past and disagree with the charges. 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. Your 
contract with the Plan says that there is a $198 deductible for diabetic self-management training, diabetic 
services and supplies.  
 
You received blood glucose test or reagent strips on April 24, 2020. The record shows that you had only paid 
$106.48 toward the $198 deductible prior to receiving the services. Therefore, you are responsible to pay the 
total allowed amount of $44.70.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category diabetic 
self-management training, diabetic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $198 deductible for diabetic self-management training, diabetic 
services and supplies. This cost sharing is a contractual obligation that had not been met at the time blood 
glucose test or reagent strips was received on April 24, 2020. Therefore, we decided that the Plan does not have 
to waive the deductible for blood glucose test or reagent strips provided on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the three port IV tubing extension set and infection control 
supplies used during anesthesia for a colonoscopy on March 5, 2020 billed with CPT codes S1015 and S8301. 
 
You asked the Plan to pay for the services as billed. You say that these codes represent items that you purchase 
at your expense and bring to the office for use in providing anesthesia care. These are not provided by the 
physician's office and should be reimbursed to you. The Plan denied your request. The Plan says these codes 
are not valid for Medicare billing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT codes S1015 and S8301 have a status indicator of "I" in the Physician Fee Schedule meaning that they are 
invalid for Medicare billing and payment purposes. Based on this information, we decided that Medicare rules 
for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to 
pay for the three port IV tubing extension set and infection control supplies used during anesthesia for a 
colonoscopy on March 5, 2020 billed with CPT codes S1015 and S8301.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray and extraction provided on June 17, 2020. 
 
You asked the Plan to pay for the intraoral x-ray and extraction. You say that you were told you were covered 
to get your tooth pulled. You say that they should have told the hospital what type of x-ray was covered. 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 
intraoral x-ray and extraction provided on June 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan and radiation therapy 
rendered from April 13, 2020 to April 18, 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. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were rendered to a male patient and 
billed with diagnosis code C50.511 (malignant neoplasm of lower-outer quadrant of right female breast). This 
diagnosis code is not appropriate for the services. 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 computed tomography (CT) scan and radiation therapy rendered from April 13, 2020 to April 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home physical therapy services (HCPCS S9131) provided to 
the enrollee from May 31, 2016 to June 23, 2016. 
 
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 plan is upholding the claim recoupment as a final claim was not found to be submitted into 
our system. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code S9131 is "Physical therapy; in the home, per diem." 
 
We find that CPT code S9131 is not supported in the medical record. Specifically, the final claim for these 
services was not submitted to the plan. 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 home physical 
therapy services (HCPCS S9131) provided to the enrollee from May 31, 2016 to June 23, 2016.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional 6 extractions provided on February 6, 2019. 
 
You asked the Plan to pay for the additional 6 extractions. You say that the provider told you that tooth 
extractions provided by an oral surgeon were not covered. The Plan denied your request. The Plan says your 
extractions benefit has been exhausted. 
 
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, extractions are limited to three 
procedures per calendar year. The record shows that you received 9 extractions on February 6, 2019, 3 of 
which were covered by the Plan, and your extractions benefit has been exhausted. Therefore, we decided that 
the Plan does not have to pay for the additional 6 extractions provided on February 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on December 3, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that it is the facility's responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the 
provider, member, or facility; therefore, payment has been properly 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 skilled nursing services provided on December 3, 
2019 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 IV tubing extension set coded S1015 and the infection 
control supplies coded S8301 provided on March 24, 2020. 
 
You asked the Plan to pay for the Iv tubing extension set and the infection control supplies. 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 payable. 
 
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 S1015 and S8301 are not supported in the medical record. Specifically, these codes 
have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Based 
on this information, we decided that Medicare rules for coverage of the IV tubing extension set and the 
infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the 
IV tubing extension set coded S1015 and the infection control supplies coded S8301 provided on March 24, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on February 10, 
2020. 
 
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 physician services provided to the enrollee on February 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ER visit from March 25, 2020 to March 
27, 2020. 
 
You asked the Plan to waive the copayment for an ER visit. You say that the hospital did not diagnose the 
enrollee in a timely manner and you are unaware of what was done during the stay due to COVID-19. The Plan 
denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $90 copayment for emergency care.  
 
The enrollee has been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency 
care benefit category. 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 an ER visit from March 
25, 2020 to March 27, 2020.