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

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on April 6, 2020. 
 
You asked the Plan to pay for the dental service. You say that you cracked your tooth while you were eating. 
You say that you had your tooth extracted. You also say that the extraction should be covered. The Plan denied 
your request. The Plan says surgical extractions are not a covered 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 surgical extraction is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical 
extraction (D7210) provided on April 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on January 19, 
2020. 
 
You asked the Plan to waive the copay for the ambulance transport. You say that this should have been covered 
by the Plan. The Plan denied your request. The Plan says that you are responsible for the 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 $225 
copay for each Medicare-covered one-way trip via ground ambulance.  
 
You have been asked to pay a $225 copay for the ambulance transport. The ambulance transport falls within 
the Medicare-covered one-way trip via ground ambulance 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 ambulance transport provided on January 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 1, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99203) provided on June 11, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not have to pay because 
you were not satisfied by the care you received. The Plan denied your request. The Plan says this processed 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 $45 
copayment for physician specialist services.  
 
You have been asked to pay a $45 copayment for an office visit with a podiatrist. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an office visit (99203) provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 31, 2020. 
 
You asked the Plan to waive the copayment for the office visit.. You say that you should not have a copayment 
for a two minute visit. The Plan denied your request. The Plan says you were charged the copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for Physician services.  
 
You have been asked to pay a $43.98 copayment for the office visit. The copayment is equal to the allowed 
amount for the service and less than your required copayment. The office visit. falls within the Physician 
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 office visit provided on 
August 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the dexamethasone injection and injection of 
eye drug provided on December 5, 2019. 
You asked the Plan to waive the cost share for the dexamethasone injection and injection of eye drug. You say 
that you are not responsible for the bill. The Plan denied your request. The Plan says the cost share 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 20% 
coinsurance for Medicare Part B covered drugs at an in-network PCP's office, specialist's office and pharmacy 
and a $25 copayment for provider and professional services at an in-network specialist's office.  
You have been asked to pay a total of $305.04 for the dexamethasone injection and injection of eye drug.  
Service Allowed Amount Standard Cost Member Liability 
Dexamethasone Injection $1,400.21 20% $280.04 
Injection of Eye Drug $25 $25 $25 
TOTAL:   $305.04 
The dexamethasone injection falls within the "Medicare Part B prescription drugs" benefit category. The 
injection of eye drug falls within the "Physician/Practitioner services, including doctor's office visits" 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 cost share for the dexamethasone injection and injection of eye 
drug provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99212) provided on July 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service was 
provided by another provider of the same specialty in the same group practice. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported unless the evaluation and management services are for unrelated problems.  
 
We looked at the file and Medicare rules. The services were in question were reported twice by physicians of 
the same specialty from the same group practice. The Plan has processed and paid one of these codes. The 
additional E&M service is not payable. 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 99212) provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient eye exam (92004) provided August 9, 2016. 
 
You asked the Plan to pay for the vision services. You say that you cannot afford to pay for this amount of $175. You live 
on your own. The Plan denied your request. The Plan says the benefit limit has been exceeded. 
 
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 these services when one routine eye exam every year. 
 
We looked at the file and the Plan's rules. The plan contract allows 1 routine eye exam every year. The records show that 
you had received this service on January 4, 2016. Therefore, the benefit maximum has been reached. Based on this 
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided 
that the Plan does not have to pay for the new patient eye exam (92004) provided August 9, 2016.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the initial hospital care on June 11, 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 that procedure code 99223 is included in 11043. 
 
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. The Plan states that code 99223 is included in 11043; however, there are no 
active NCCI edits for these codes. The Plan has not provided any documentation or Medicare rules to show that 
code 99223 is not separately payable. Therefore, we decided that the Plan has to pay for the initial hospital care 
on June 11, 2020.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care rendered on June 4, 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. Medicare rules say that E/M services must be billed with modifier -25 
when reported with code 99406. 
 
We looked at the file and Medicare rules. The file shows that E/M code 99223 was not billed with the required 
-25 modifier. 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 initial hospital care rendered on June 
4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the trifocal eyeglass lenses (V2303 x 2) rendered by the out 
of network (OON) provider on July 31, 2020. 
 
 
You asked the Plan to pay for the eyeglass lenses. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the eyeglass lenses are not a covered 
benefit as they were provided by a non-plan optical facility. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. Additionally, 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. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglass lenses have not been met. Specifically, the Plan contract states that the eyewear 
allowance is provided once every twenty four months for you to use toward the purchase price of eyewear from 
a plan optical facility. The provider in this case is not an in-network provider with the Plan. The Plan has 
network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the 
items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for the trifocal eyeglass lenses (V2303 x 2) rendered by the out of network 
(OON) provider on July 31, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the physical therapy (PT) services on September 8, 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 that the therapy cap was met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. The rules say that an exception to the therapy cap may be made for documented medically necessary 
services. 
 
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 medically necessary. Our physician reviewer found the records support that the requested therapy 
is generally accepted as specific and effective therapy for the enrollee's condition. The enrollee's two-minute 
walk test goal was 100 meters and her two-minute test could not be measured on August 31, 2020, due to being 
on room isolation. Her most recent treatment indicated she ambulated 50 feet with a walker. The records 
indicate the goal was still in progress as of August 31, 2020. The enrollee required the unique skills of a 
professional therapist to safely and effectively provide treatment. The services were reasonable and medically 
necessary and are an exception to the therapy cap. 
 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the physical therapy (PT) services on September 8, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 30, 2019, by an 
OON provider. 
 
You asked the Plan to pay for an eye exam. You say that the enrollee could not choose an in-network 
optometrist. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 December 30, 
2019, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture. 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services exceed your benefit 
limit. 
 
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. Review of the file shows that you are requesting a partial denture. 
Partial dentures are covered once every five years. You last received a partial denture on March 22, 2018. Five 
(5) years have not passed since you last received a partial denture. Therefore, we decided that the Plan does not 
have to pre-approve a maxillary partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related medical services provided on 
April 6, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit and related medical services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
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 and related medical services 
provided on April 6, 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 scratch resistant coating (V2760) provided on June 26, 
2020. 
 
You asked the Plan to pay for the scratch resistant coating (V2760). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services. Therefore, we decided that 
the Plan does not have to pay for the scratch resistant coating (V2760) provided on June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient provider services provided July 19, 2018. 
 
You asked the Plan to pay for the inpatient provider services. You say that you have attached your computer 
generated filing report which shows that you sent this claim on 08/10/2018. Kindly review all documents and 
remit payment. The Plan denied your request. The Plan says the initial claim submission was not filed within 
12 months of the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient provider services was not filed until June 16, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the inpatient provider services provided July 19, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral exam (D0150) and panoramic 
radiographic images (D0330) provided on July 28, 2020. 
 
You asked the Plan to pay for comprehensive oral exam and panoramic images. You say that the services 
should be covered. The Plan denied your request. The Plan says you have exhausted your maximum benefit 
frequency for these 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. This benefit includes one 
comprehensive exam (D0150) every three plan years and one panoramic X-ray (D0330) every three plan years. 
 
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. Specifically, the records show you last received these services in 2018. 
This means the current services were received within three years of the last and are not covered. Therefore, we 
decided that the Plan does not have to pay for comprehensive oral exam (D0150) and panoramic radiographic 
images (D0330) provided on July 28, 2020.
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 from 
March 2, 2020 to March 3, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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, the claims 
were not initially billed under UB-04 in order to establish the required HHA reports on the 0023 revenue 
code line the date of the first covered visit provided during the initial episode. Therefore, we decided that the 
Plan does not have to pay for the home health services provided to the enrollee from March 2, 2020 to March 3, 2020.