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

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) and a partial 
ostectomy/sequestrectomy (D7550) provided on September 9, 2020. 
 
You asked the Plan to pay for the dental services.. You say that your oral surgeon determined that you needed 
this x-ray as part of a post-operative evaluation of a problem site. The partial ostectomy/sequestrectomy was 
also provided as a follow-up to a previous procedure. You would like an exception for these services based on 
medical necessity. The Plan denied your request. The Plan says while a panoramic x-ray is a covered service, 
the Plan previously paid for a complete series of x-rays in February of 2016. A complete series or panoramic x-
ray can only be covered once in a 5-year calendar period. Additionally, a partial ostectomy/sequestrectomy is 
not a service that is covered by Medicare or by the Plan's supplemental dental benefit under any circumstance. 
 
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 or were provided in a frequency in excess of what the Plan allows. 
Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) and a partial 
ostectomy/sequestrectomy (D7550) provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted procedure, nervous system (CPT code 64999-59-50) 
provided to the enrollee on October 8, 2020. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
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 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 service. Our physician reviewer found 
the review indicates that the billed services were not supported. The documentation submitted during the 
course of the original investigation was again thoroughly reviewed. A complete description of the unlisted code 
billed was not submitted. In addition, the submitted medical records do not include detailed procedure note to 
support that unlisted procedure, nervous system was performed. The review has determined that the services 
were not supported by the records provided for review. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for unlisted procedure, nervous system (CPT code 64999-59-50) provided to the enrollee on 
October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the heart monitor evaluation (G2066) 
provided November 14, 2020. 
 
You asked the Plan to waive the copayment for the heart monitor evaluation. You say that you do not agree 
with this copayment. The Plan denied your request. The Plan says the copayment has processed correctly and 
no reimbursement is due. 
 
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 outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $20 copayment for the heart monitor evaluation. This service 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 the heart monitor evaluation (G2066) provided November 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical supplies (S1015, S8301) provided June 11, 2020. 
 
You asked the Plan to pay for the items. You say that these items were medically necessary. The Plan denied 
your request. The Plan says the codes billed are not eligible for Medicare payment. 
 
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, & S8301 are not supported in the medical record. Specifically, per the  2020 National Physician Fee Schedule, these codes are marked with a status code of "I" which means they are invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Therefore, we 
decided that the Plan does not have to pay for medical supplies (S1015, S8301) provided June 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hip replacement provided from May 
19, 2020, to May 20, 2020. 
 
You asked the Plan to waive the coinsurance for the hip replacement. You say that this was charged as 
outpatient but both surgeries were the same. You say that you should not be charged the greater amount. The 
Plan denied your request. The Plan says the coinsurance 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% of 
the cost for each in-network, Medicare-covered visit to an outpatient hospital facility, certified ambulatory 
surgical center, or clinic.  
 
You have been asked to pay $1,701.74, which is less than the 20% coinsurance for the hip replacement. The 
hip replacement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers" benefit category. The records show the hip replacement was billed as an 
outpatient procedure.  
 
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 the hip replacement provided from May 19, 2020, to May 
20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit and x-ray.

You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these services are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the services at issue are not manual manipulation of the spine. Office visits and x-rays are not covered when provided by a chiropractor. Therefore, we decided that the Plan does not have to pay for the chiropractic office visit and x-ray.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on November 9, 
2020. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you had colonoscopies in the 
past and never had a copayment. You say that you did not know there would be a copayment. The Plan denied 
your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment for each visit to an outpatient hospital facility. 
 
You have been asked to pay a $200 copayment for the colonoscopy. The colonoscopy 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 the colonoscopy provided 
on November 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug test(s), presumptive, any number of drug classes, any 
number of devices or procedures; by instrument chemistry analyzers (CPT code 80307) and drug test(s), 
definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between 
structural isomers (CPT Code G0482) provided to the enrollee on April 30, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Current Procedural Terminology (CPT) code 80307 (1 Unit) remains not supported. The place of service on the 
CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The 
submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the 
submitted medical documentation and/or claim history indicates that the specimen was obtained in an 
Emergency room setting POS 23.  Also, the laboratory results submitted indicate the specimen was collected 
on 04/30/2020 and received by the lab on May 12, 2020.  Of note, the patient resides in MO and the billing 
laboratory is located in IL; therefore, the billed code cannot be verified.  It is noted multiple attempts were 
made to obtain additional information from the provider. 
 
 Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 Unit) remains not supported. The 
place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained 
in an Emergency Room POS 23.  Also, the laboratory results submitted indicate the specimen was collected on 
04/30/2020 and received by the lab on May 12, 2020. Of note, the patient resides in MO and the billing 
laboratory is located in IL; therefore, the billed code cannot be verified.  It is noted multiple attempts were 
made to obtain additional information from the provider. 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 drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument 
chemistry analyzers (CPT code 80307) and drug test(s), definitive, utilizing (1) drug identification methods 
able to identify individual drugs and distinguish between structural isomers (CPT Code G0482) provided to the 
enrollee on April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lenses (V2202) and frames (V2020) received on October 12, 
2020. 
 
You asked the Plan to pay for lenses and frames. You say that the provider contacted the Plan and was told the 
service was covered. The Plan denied your request. The Plan says reimbursement was denied because an out-
of-network provider rendered the service. 
 
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 using an in-network provider. 
 
We looked at the file and the Plan's rules. An out-of-network provider was used. Based on this information, we 
decided that the Plan's rules for coverage of lenses and frames have not been met. Specifically, services were 
provided by an out-of-network provider without prior authorization. The Plan has contracted providers 
available to provide these 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 lenses (V2202) and frames (V2020) 
received on October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the preventive procedure, prefabricated post and core in addition to 
crown, and root canal provided on December 21, 2020. 
 
You asked the Plan to pay for the preventive procedure, prefabricated post and core, and root canal. You say 
that you told the provider that your maximum benefit was exhausted. The Plan denied your request. The Plan 
says that the maximum allowed for comprehensive services for the 2020 calendar year had been met. 
 
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 did not provide a copy of the applicable 2020 Evidence of Coverage 
for this case. We asked for the 2020 Evidence of Coverage, but it was not provided to us. Without this 
information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or 
that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan 
has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the 
preventive procedure, prefabricated post and core in addition to crown, and root canal provided on December 
21, 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 screening telephone consultation provided on November 11, 
2020. 
 
You asked the Plan to pay for the screening consultation. The Plan denied your request. The Plan says this is 
not a covered service. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The service at issue in this appeal, the consultation, was requested solely for screening purposes. Medicare does 
not cover this service solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for screening telephone consultation provided on November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) as defined by codes 
A5501 and A5513 for billed date October 22, 2020. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the submitted Delivery Ticket does not support that these specific items were delivered to the 
enrollee. 
 
The Plan must follow Medicare rules. The rules state that the preferred method to identify items delivered is 
use of a brand name and model number, brand name and serial number, or manufacturer name and part number 
to identify the product. If this type of information is not available for the product, suppliers may use a detailed-
narrative description of the item; however, it must contain sufficient descriptive information to allow a proper 
coding determination.  
 
The record does not contain a valid proof of delivery to support medical necessity for the supplies provided in 
this case. the submitted Delivery Ticket lists the item as JIONS Unisex Men Women Adjustable Velco Wide 
Shoes Swollen Feet Diabetic Edema Boos Slippers and Dr. Scholl`s Women`s Guaranteed Comfort Diabetic 
and Circulatory crew 4 pack socks. The submitted order is for HCPCS code A5501, for diabetics only, fitting 
(including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom 
molded shoe), per shoe and A5513, For diabetics only, multiple density insert, custom molded from model of 
patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of 
shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each.  
 
The submitted Delivery Ticket does not support that these specific items were delivered to the member. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) as defined 
by codes A5501 and A5513 for billed date October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure, topical application of fluoride 
varnish, and periodontal maintenance provided on October 7, 2020. 
 
You asked the Plan to pay for the preventive procedure, topical application of fluoride varnish, and periodontal 
maintenance. You say that you would like these services to 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 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 
preventive procedure, topical application of fluoride varnish, and periodontal maintenance provided on October 
7, 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 first 
intraoral periapical x-ray provided on November 11, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that the treating provider is in-network with the Plan. 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 
problem focused limited oral evaluation and first intraoral periapical x-ray provided on November 11, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on 
September 16, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you thought the 
colonoscopy was covered. You say you had polyps removed. The Plan denied your request. The Plan says you 
have been asked to pay the correct cost-sharing 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 $285 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.  
 
You have been asked to pay a $285 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy 
falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. The record shows polyps were removed which makes the colonoscopy 
diagnostic in nature. 
 
 
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 diagnostic colonoscopy provided on September 16, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on October 13, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
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 a knee orthosis with 
suspension sleeve (L1833, L2397) provided to the enrollee on October 13, 2020.