Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing care provided from February 14, 2020 
through March 31, 2020. 
 
You asked the Plan to pay for skilled nursing care. The Plan denied your request. The Plan says SNF level 
services are not a covered benefit while on hospice.  
 
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 skilled nursing care provided from February 14, 2020 through 
March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for educational supplies (99071) provided on December 30, 
2019. 
 
You asked the Plan to pay for educational supplies. You say that this should be covered. The Plan denied your 
request. The Plan says payment for this service is included in the payment of other services. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for codes with a status code of B is 
bundled into payment for other services not specified.  
 
We looked at the file and Medicare rules. Payment for the service at issue is bundled into payment of other 
services. Based on this information, we decided that Medicare rules for coverage of educational supplies have 
not been met. Therefore, we decided that the Plan does not have to pay for educational supplies (99071) 
provided on December 30, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cell enumeration using immunologic selection and 
identification in fluid specimen services coded 86152 and 86153, the immunofluorescence services coded 
88346 and 88350 provided on January 9, 2020. 
 
You asked the Plan to pay for the Cell enumeration using immunologic selection and identification in fluid 
specimen services and the immunofluorescence services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 86152, 86153, 88346, and 88350 are not supported in the medical record. Specifically, 
there is a more appropriate/accurate code to report the services billed. Based on this information, we decided 
that Medicare rules for coverage of the Cell enumeration using immunologic selection and identification in 
fluid specimen services and the immunofluorescence services have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cell enumeration using immunologic selection and identification in fluid 
specimen services coded 86152 and 86153, the immunofluorescence services coded 88346 and 88350 provided 
on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on March 2, 2020. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation (D0180). You say that you couldn't 
locate an in-network periodontist. You say that insurance should pay more. The Plan denied your request. The 
Plan says the service is 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 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 
comprehensive periodontal evaluation (D0180) provided on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and endodontic therapy 
(D3330) provided on April 21, 2020. 
 
You asked the Plan to pay for the limited oral evaluation (D0140) and endodontic therapy (D3330). You say 
that this was an emergency and the only doctor you could find was out-of-network. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
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 limited oral evaluation every plan year. The Plan paid for a limited oral evaluation provided on April 17, 
2020, which exhausted your benefit. The endodontic therapy is not a covered supplemental benefit. Therefore, 
we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and endodontic therapy 
(D3330) provided on April 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle foot orthosis (L1971) provided on February 25,
2020.
You asked the Plan to pay for an ankle foot orthosis. You say that this was billed correctly. The Plan denied
your request. The Plan says the submitted documents do not contain proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery. No proof of delivery or delivery ticket was included in
the submitted documentation. 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 an ankle foot
orthosis (L1971) provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture provided on December 10, 2019.
You asked the Plan to pay for the complete upper denture. You say that you were informed that you were
covered. You say that you were not informed the dentist was out-of-network. The Plan denied your request.
The Plan says out-of-network dental 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 when received from an out-of-network provider. Therefore, we decided
that the Plan does not have to pay for the complete upper denture provided on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an abutment (D6056) and crown (D6059) provided
February 25, 2020.
You asked the Plan to pre-approve the abutment and crown. You say that you didn't know the service would
not be covered at the time you began the process to have the crown installed. The Plan denied your request.
The Plan says the services at issue are not covered benefits for 2020.
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 pre-approve an
abutment (D6056) and crown (D6059) provided February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81225, 81226, 81227, 81230, 
81231, 81240, 81241, 81328, 81335, 81355, 81323, 81283, and 81408 provided on February 18, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were not billed correctly. 
 
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 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81328, 81335, 81355, 81323, 
81283, and 81408 are not supported in the medical record. Specifically, the place of service  on the CMS-1500 
form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim 
form indicates the laboratory specimen was obtained in a laboratory, place of service 81, however, the 
submitted medical documentation and/or claim history indicates that the specimen was obtained in an office 
setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81328, 81335, 81355, 81323, 
81283, and 81408 provided on February 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit-after regularly scheduled hours (D9440) 
provided April 28, 2020. 
 
You asked the Plan to pay for the office visit. You say that due to Covid your dentist was in a mandatory shut 
down for appointments with the exception of emergencies. Seeing that your tooth was cracked he suggested an 
emergency appointment. The Plan denied your request. The Plan says this service is not covered under the plan 
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. The health plan contract says 
any services not listed under the covered dental procedures is not covered. 
 
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 office 
visit-after regularly scheduled hours (D9440) provided April 28, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from April 4, 2020 to 
April 14, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
elected hospice on April 4, 2020. The Plan also says that the enrollee was clinically stable, not in acute distress, 
and did not required daily skilled nursing services. 
 
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 skilled nursing services provided from April 4, 2020 to 
April 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided by a participating 
provider on February 5, 2020 to March 9, 2020. 
 
You asked the Plan to waive the copayment for lab work. You say that you do not understand these charges. 
The Plan denied your request. The Plan says the correct copayments have been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for outpatient diagnostic tests/in-network/lab services at an outpatient hospital.  
 
You have been asked to pay a total of $50.65 ($18.05 + $3 + $29.60 = $50.65) for lab work. This lab work was 
provided at an outpatient hospital facility; therefore, the correct copayments have been applied. Lab work falls 
within the outpatient diagnostic tests/in-network/lab services at an outpatient hospital 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 lab work provided by a participating provider on February 
5, 2020 to March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Apicoectomy (D3410) and dental re-evaluation (D0170) 
provided January 30, 2020 to February 17, 2020. 
 
You asked the Plan to pay for the Apicoectomy and dental re-evaluation. You say that these services were 
medically necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits 
under your dental plan. 
 
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 an 
Apicoectomy (D3410) and dental re-evaluation (D0170) provided January 30, 2020 to February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the antigen therapy services (95165) and 
the allergen immunotherapy injection (95115) provided on April 1, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 
has been applied correctly to the services provided. 
 
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 per visit to a specialist.   
 
You have been asked to pay a $20 copayment for the treatment provided by a specialist. 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 antigen therapy services (95165) and the allergen immunotherapy 
injection (95115) provided on April 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper and lower dentures (D5110, D5120). 
 
You asked the Plan to pre-approve complete upper and lower dentures. You say that the requested items are 
necessary. The Plan denied your request. The Plan says the requested items 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
complete upper and lower dentures (D5110, D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided February 20, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically
necessary. The Plan denied your request. The Plan says the enrollee's needs could be met in the outpatient
setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the record did not show that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier emergency and/or
observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided February 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray (70145) provided March 20, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that the service was medically necessary. The Plan 
denied your request. The Plan says an incorrect diagnosis code was used. 
 
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 code 71045 is not supported in the medical record. Specifically, the diagnosis code Z13.6 
notes a planned screening test, however, the place of service was an Emergency room which indicates the 
encounter was unplanned. The place of service does not match the diagnosis code used. Based on this 
information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we 
decided that the Plan does not have to pay for a chest x-ray (70145) provided March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care office visit (99213) provided on March 11, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 per visit for urgently needed care. You have been asked to pay a $20 copayment for the urgent care service provided. 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 urgent care office visit (99213) provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for immunotherapy services provided on 
February 3, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that these services are not supposed 
to have a copayment. The Plan denied your request. The Plan says the copayment amount you are being 
charged is correct. 
 
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 
copayment for immunotherapy provided in a specialist's office.  
 
You have been asked to pay $20 copayment for specialist services. Specialist services 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 copayment for immunotherapy services provided on February 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for colonoscopy services (CPT 45380) provided to the enrollee
from November 8, 2019 to November 11, 2019.
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 bundled services are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that CPT code
45380 has a bundled relationship with CPT code 45385 and cannot be paid as billed. This code cannot be paid
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore,
we decided that the Plan does not have to pay for colonoscopy services (CPT 45380) provided to the enrollee
from November 8, 2019 to November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01936, 99100) rendered by the out of 
network (OON) provider on March 30, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the anesthesia services (01936, 99100) rendered by the out of network (OON) provider 
on March 30, 2020.