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

We decided that the Plan does not have to waive the out of network cost share forthe limited oral evaluation (D0140), the periapical x-ray (D0220), and the filling (D2393) provided on June 11, 2020.You asked the Plan to waive the out of network cost share forthe dental services. You say that there are no in network dentist within 65 miles of you. You say that you were advised to go to a dental office who you were told 35 miles away. You also say that that dental office is actually 65 miles away.The Plan denied your request. The Plan says the dental provider in this case is not a network provider. The Plan says that when you receive services out of network, you may be billed any amount greater than the MAC payment made by the plan to the provider.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 may be billed any amount greater than the MAC payment made by the plan to the provider when you receive services out of network. The member out of network liability is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, the record shows that the recommended dental office is 57 miles away from your residence.Therefore, we decided that the Plan does not have to waive the out of network cost share forthe limited oral evaluation (D0140), the periapical x-ray (D0220), and the filling (D2393) provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide 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 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 physician services provided 
by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advance care planning (99497, 99498) provided. 
 
You asked the Plan to pay for the advance care planning. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the Medicare hospice benefit, through 
fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or 
revocation. 
 
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 the advance care planning (99497, 99498) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the full amount for the comprehensive periodontal 
evaluation (D0180) provided on June 24, 2020. 
 
You asked the Plan to reimburse the full amount for the dental service. You say that you determined that this 
provider was in network on the plan's website. You say that you paid $213 at the time you received the service. 
You say that you were only reimbursed $75. You also say that you would not have seen this provider if you 
had known they were out of network. The Plan denied your request. The Plan says the provider in this case is 
not a network provider. The Plan also says that out of network provides may bill you for any amount greater 
than the payment made to the provider. 
 
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, out of network providers may bill you 
for any amount greater than the payment made by the Plan to the provider. The record shows that the Plan paid 
the allowed amount for the comprehensive periodontal evaluation. Therefore, we decided that the Plan does not 
have to reimburse the full amount for the comprehensive periodontal evaluation (D0180) provided on June 24, 
2020.  
 
Your complaint about incorrect information on the Plan?s website is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic external defibrillator (K0606) 
 
You asked the Plan to pay for an automatic external defibrillator. You say that this was medically necessary. 
The Plan denied your request. The Plan says this was not billed with a covered diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that there are specific ICD-10 codes that support 
medical necessity for HCPCS codes K0606-K0609. 
 
We looked at the file and Medicare rules. The billed diagnosis, E85.9, is not listed as supporting medical 
necessity for the item at issue. Based on this information, we decided that Medicare rules for coverage of an 
automatic external defibrillator have not been met. Therefore, we decided that the Plan does not have to pay for 
an automatic external defibrillator (K0606)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic mammography, including computer-aided 
detection (CAD) when performed (77065) bilateral breast ultrasound (76642) and diagnostic digital breast 
tomosynthesis (G0279) provided June 22, 2020 
 
You asked the Plan to pay for diagnostic services. You say that according to the medical provider you were 
billed because your deductible started over July 1st. Since these test were done in June, why would the 
deductible have to be applied to this test? The Plan denied your request. The Plan says this claim was processed 
correctly and the deductible applied per the Evidence of Coverage. 
 
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 $150 deductible. 
 
The item or service you asked the Plan to pay for falls within the benefit category Outpatient diagnostic tests, 
therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is $150 deductible for outpatient diagnostic tests, therapeutic services and supplies. This cost sharing 
is a contractual obligation that had not been met at the time diagnostic services was received on June 22, 2020. 
Therefore, we decided that the Plan does not have to pay for the diagnostic mammography, including 
computer-aided detection (CAD) when performed (77065) bilateral breast ultrasound (76642) and diagnostic 
digital breast tomosynthesis (G0279) provided June 22, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on 
February 7, 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 services of a licensed surgical assistant are not eligible for separate reimbursement. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. The provider is a Licensed Surgical Assistant (LSA). Medicare only makes payment for surgical 
assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan 
does not have to pay for assistant surgeon services provided to the enrollee on February 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services with CPT codes 19357ASRT and 
19357ASLT provided on April 7, 2020. 
 
You asked the Plan to pay for the surgical services. 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 as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 19357 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the surgical services have not been met. 
Therefore, we decided that the Plan does not have to pay for the surgical services with CPT codes 19357ASRT 
and 19357ASLT provided on April 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forintravenous infusions provided from January 2, 2020, to January 6, 2020.You asked the Plan to waive the copayments forintravenous infusions. You say that you only ever paid a $20 copayment and started receiving bills for higher amounts.The Plandenied 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 $20 copayment for physician/practitioner services, including doctor's office visits. You received intravenous infusions from January 2, 2020, to January 6, 2020 for a total of 3. Therefore, you are responsible to pay a $20 copayment per each infusion. The total amount you owe is: $60. You have been asked to pay the total copayment amount of $60 for intravenous infusions. Intravenous infusions fall 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 copayments forintravenous infusions provided from January 2, 2020, to January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 23, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 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 May 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not know there 
would be a copayment. The Plan denied your request. The Plan says you were charged this cost sharing 
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 $225 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $225 for these 
services. 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 ambulance services provided.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit provided on December 22, 2019. 
 
You asked the Plan to pay for emergency department visit. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service 
Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. 
During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to 
the terminal illness until the first day of the month following the month in which hospice was revoked or 
discharged. 
 
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 emergency department visit provided on December 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered from January 21, 2020 to 
April 7, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered from January 21, 2020 to April 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotics rendered on June 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 the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the orthotics rendered on 
June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical 
x-ray (D0230), and the unspecified preventive procedure (D1999) provided on July 1, 2020. 
 
You asked the Plan to pay for the periapical x-rays and unspecified preventive procedure. You say that you 
were advised by a plan representative that this dental provider was in network. The Plan denied your request. 
The Plan says peripical x-rays are not listed as a covered service. The Plan says that unspecified preventive 
procedure is not listed as a covered service either. 
 
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 dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial 
periapical x-ray (D0220), the additional periapical x-ray (D0230), and the unspecified preventive procedure 
(D1999) provided on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays and periodic oral evaluation provided on 
July 14, 2020. 
 
You asked the Plan to pay for the bitewing x-rays and periodic oral evaluation. You say that the exam is part of 
the cleaning and 3 years is too long between x-rays. You say that you are appealing the denial of payment. The 
Plan denied your request. The Plan says your benefit is 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, you also have a maximum benefit of 
one bitewing x-ray every three years and one oral exam every year. You received bitewing x-rays provided on 
October 1, 2018 and a periodic oral evaluation provided on October 25, 2019, which exhausted your benefits. 
Therefore, we decided that the Plan does not have to pay for the bitewing x-rays and periodic oral evaluation 
provided on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on January 2, 
2020. 
 
You asked the Plan to pay for this service. You say that this physician visit should be covered by the Plan. The 
Plan denied your request. The Plan says you 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 out of network physician services provided on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) provided. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says the appropriate codes were not used to report the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted is lacking the correct 
codes required by Medicare to allow payment for this testing, as stated above. Therefore, we decided that the 
Plan does not have to pay for Comprehensive Genomic Profile (CGP) provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 20, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
laboratory 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 laboratory services provided on March 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999) provided on 
June 8, 2020. 
 
You asked the Plan to pay for the dental service. You say that you have the enhanced dental and vision 
package. You say that this service should be covered. The Plan denied your request. The Plan says unspecified 
preventive procedure 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 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 
unspecified preventive procedure (D1999) provided on June 8, 2020.