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

 
We decided that the Plan does not have to reimburse you for eyeglasses purchased from an out-of-network 
provider on May 27, 2020. 
 
You asked the Plan to reimburse you for eyeglasses. You say that the Plan owes you $180 towards the 
eyeglasses. The Plan denied your request. The Plan says you are not eligible for reimbursement through the 
out-of-network provider. 
 
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 allows a $115 benefit towards the purchase of eyeglasses from an in-network provider. 
 
We looked at the file and the Plan's rules. The glasses were purchased from an out-of-network provider. Based 
on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, 
we decided that the Plan does not have to reimburse you for eyeglasses purchased from an out-of-network 
provider on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on 
August 12, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were advised that 
this provider was out-of-network. You also say that you were told that you could submit claims to your 
insurance for reimbursement. The Plan denied your request. The Plan says these services were rendered by a 
dentist that has opted out of Medicare participation. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation and prophylaxis provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided by an 
out of network (OON) provider. 
 
You asked the Plan to pay for dermatology services. You say that you had a difficult time finding a provider. 
You say that you were told that the Plan would work with you. The Plan denied your request. The Plan says 
prior authorization was not obtained. The Plan says that there are in-network providers available for these 
services. 
 
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 dermatology services provided on January 13, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of spinal neurostimulator electrodes 
(63650) and implantable neurostimulator electrode (L8680) 
 
You asked the Plan to pre-approve the implantation of spinal neurostimulator electrodes and implantable 
neurostimulator electrode. You say that these services are medically necessary for enrollee. The Plan denied 
your request. The Plan says these services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators are only covered under certain 
medical indications. 
 
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 pre-approve the implantation of spinal 
neurostimulator electrodes and implantable neurostimulator electrode. Our reviewer says that the request is 
considered not medically reasonable or necessary. Our physician reviewer found this is considered an 
experimental and/or investigational procedure for chronic pelvic pain. 
 
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 implantation of spinal neurostimulator electrodes and implantable 
neurostimulator electrode have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the implantation of spinal neurostimulator electrodes (63650) and implantable neurostimulator electrode 
(L8680)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network chiropractic services provided to the enrollee 
on September 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 chiropractic 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 chiropractic 
services provided to the enrollee on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 
11, 2020. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you believe that the service was coded 
incorrectly. You also say that you thought you were going to receive the remainder of the periodontal scaling 
and root planing. The Plan denied your request. The Plan says this service is not a covered benefit. The Plan 
also says that at the time of service you signed a treatment plan acknowledging that you would be fully 
responsible for the charges for periodontal maintenance. 
 
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 
periodontal maintenance (D4910) provided on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction of all upper and lower teeth (D7210) to be 
provided by an oral surgeon. 
 
You asked the Plan to pre-approve this service. You say that the dental extractions are medically necessary. 
The Plan denied your request. The Plan says dental services provided by an oral surgeon are not covered. 
Additionally, coverage for dental extractions is limited to one extraction per year when performed by a 
participating general dentist. 
 
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.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the Plan provides coverage of only one dental 
extraction per year when provided by a participating general dentist. Therefore, we decided that the Plan does 
not have to pre-approve the extraction of all upper and lower teeth (D7210) to be provided by an oral surgeon.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulmonary perfusion imaging (78580) provided on August 5, 
2020. 
 
You asked the Plan to pay for the pulmonary perfusion imaging. You say that you would like reconsideration 
because this service was denied as a duplicate in error. The Plan denied your request. The Plan says the 
submitted documentation supports 1 unit of 78580-26, which was previously approved/paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that claim lines that have been determined to be exact duplicates of another claim or claim line 
are denied. 
 
We find that CPT code 78580 is not supported in the record. Specifically, the documentation submitted 
supports one unit of pulmonary perfusion imaging. The record indicates that one unit of this service was 
previously processed and paid. Based on this information, we decided that Medicare rules for coverage of the 
pulmonary perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pay for 
pulmonary perfusion imaging (78580) provided on August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the 
complete series x-ray (D0210) provided. 
 
You asked the Plan to pay for the dental services. You say that when you asked the provider if they accepted 
your insurance, the provider advised yes. You say that you had no idea that this dentist that you have been 
going to for 20 years was out of network. You say that there is no other dentist near you. You also say that you 
cannot afford this bill. The Plan denied your request. The Plan says the provider in this case is out of network. 
The Plan says that the provider was out of network in 2019 too. The Plan says that out of network providers 
can bill you for the unpaid portion of the bill. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you may still be billed by an out of 
network provider for any amount greater than the MAC payment made by the plan to the provider. Therefore, 
we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the 
complete series x-ray (D0210) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), pulp vitality 
test (D0460), cone beam CT capture and interpretation with limited field of view (D0364), and the incomplete 
root canal (D3332) provided from August 27, 2020, to August 28, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that although the root canal was not 
completed, the viability of the tooth and crown would not have been determined without this procedure. The 
Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says the 
frequency limit for this service has been exceeded. The Plan also says that the pulp vitality test, cone beam CT 
with interpretation, and the incomplete root canal are not listed as covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 limited oral 
evaluation per plan year has been exceeded. The record shows that the Plan paid for the limited oral evaluation 
that you received on August 31, 2020. Additionally, the pulp vitality test, cone beam CT capture and 
interpretation, and incomplete root canal are not among those covered under this benefit. The Evidence of 
Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does 
not have to reimburse you for the limited oral evaluation (D0140), pulp vitality test (D0460), cone beam CT 
capture and interpretation with limited field of view (D0364), and the incomplete root canal (D3332) provided 
from August 27, 2020, to August 28, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ER visit, the EKG, the arm surgery, 
and the jaw surgery provided from June 3, 2020, to June 10, 2020. 
 
You asked the Plan to waive the copayments for the ER visit, the EKG, the arm surgery, and the jaw surgery. 
You say that you need assistance with your bills. You say you have never had a large health insurance claim. 
The Plan denied your request. The Plan says you have been charged 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 $50 
copayment for each emergency room visit, a $50 copayment for Medicare-covered non-radiological diagnostic 
services when performed in an in-network hospital, outpatient facility, or a free-standing facility imaging or 
diagnostic center, and a $50 copayment for Medicare-covered surgery or other services at an in-network 
outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges 
and physician or surgical charges.  
 
 
  
You have been asked to pay a $50 copayment for the ER visit, a $50 copayment for the EKG, a $50 copayment 
for the arm surgery, and a $50 copayment for the jaw surgery. The ER visit falls within the ?Emergency Care? 
benefit category. The EKG falls within the ?Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies? benefit category. The arm surgery and the jaw surgery 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 copayments for the ER visit, the EKG, the arm surgery, and a jaw the 
surgery provided from June 3, 2020, to June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 3, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-
network with the Plan and authorization was not obtained. 
 
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 3, 2020, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes 
(97110) manual therapy techniques (97140) and application of a modality to 1 or more areas; whirlpool 
(97022) provided May 21, 2018 to May 24, 2018. 
 
You asked the Plan to pay for the physical therapy services. You say that required proof of timely filing and 
corresponding EOB's are attached. Please reprocess the medical bill to be considered as filed timely. The Plan 
denied your request. The Plan says the time limit for filing has expired. 
 
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 physical therapy services was not filed until August 18, 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 therapeutic procedure, 1 or more areas, each 15 minutes (97110) 
manual therapy techniques (97140) and application of a modality to 1 or more areas; whirlpool (97022) 
provided May 21, 2018 to May 24, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99233) provided on June 21, 2020, 
through June 23, 2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says the manifestation code cannot be billed 
in the primary position. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also that that the ICD-10-CM has a coding convention that requires the underlying condition be 
sequenced first, if applicable, followed by the manifestation. 
 
We find that CPT code 99233 is not supported in the record. Specifically, this claim was billed with diagnosis 
code J91.0 in the primary position. J91.0 has a code first note indicating that the underlying condition should be 
sequenced first on the claim. Based on this information, we decided that Medicare rules for coverage of the 
subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for 
subsequent hospital care (99233) provided on June 21, 2020, through June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on July 23, 2020. 
 
You asked the Plan to pay for lumbar-sacral orthosis. You say that you are appealing with supporting 
documentation. The Plan denied your request. The Plan says the denial of payment for this item is correct, 
because the doctor's notes submitted do not document that a brace with code L0650 was ordered. 
 
The Plan must follow Medicare rules. Medicare rules say that lumbar-sacral orthosis L0650 requires a face-to-
face encounter supporting the need for the item.  
 
We looked at the file and Medicare rules. The documentation submitted does include a telemedicine encounter 
with the enrollees treating physician; however, this visit recommended a lumbar-sacral orthosis L0637 which 
does not match the item billed on this claim. Based on this information, we decided that Medicare rules for 
coverage of lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay 
for a lumbar-sacral orthosis (L0650) provided on July 23, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an unlisted multianalyte assay with algorithmic analysis (81599) 
and oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping 
genes (81521). 
 
You asked the Plan to pre-approve an unlisted multianalyte assay with algorithmic analysis and oncology 
(breast), mRNA, microarray gene expression profiling. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an unlisted multianalyte assay with 
algorithmic analysis and oncology (breast), mRNA, microarray gene expression profiling. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found a mammoprint has a category 1 recommendation. If the mammoprint score is low, adjuvant 
chemotherapy is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an unlisted multianalyte assay with algorithmic analysis and oncology (breast), 
mRNA, microarray gene expression profiling have been met. Therefore, we decided that the Plan has to pre-
approve an unlisted multianalyte assay with algorithmic analysis (81599) and oncology (breast), mRNA, 
microarray gene expression profiling of 70 content genes and 465 housekeeping genes (81521).  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921) and localized delivery of 
antimicrobial agents (D4381) provided on September 9, 2020. 
 
You asked the Plan to pay for the gingival irrigation and localized delivery of antimicrobial agents. You say 
that you were advised that the deep cleaning procedure was a covered benefit. The Plan denied your request. 
The Plan says these 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 
gingival irrigation (D4921) and localized delivery of antimicrobial agents (D4381) provided on September 9, 
2020.