Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on May 15, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided to the enrollee by an out-of-network provider 
on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis 
(specify substance or drug) initial hour (96365) intravenous infusion, for therapy, prophylaxis, or diagnosis 
(specify substance or drug) each additional hour (96366) vancomycin hcl injection, 500 mg (J3370) provided 
on June 27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the injection services. You say that please review the attached paperwork and 
reconsider the decision on the denial based on the medical necessity found in the medical records. The Plan 
denied your request. The Plan says enrollee's must receive their medical services from an in-network provider 
with the exception being urgent or emergent services. Non-emergent services with non-contracted providers 
require prior authorization before services being rendered. 
 
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 intravenous infusion, for therapy, prophylaxis, or 
diagnosis (specify substance or drug) initial hour (96365) intravenous infusion, for therapy, prophylaxis, or 
diagnosis (specify substance or drug) each additional hour (96366) vancomycin hcl injection, 500 mg (J3370) 
provided on June 27, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services (CPT 72070 and CPT 72040) provided to the 
enrollee on July 15, 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 provider needs to consider appropriate modifier usage. 
 
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, the CPT Code Manual definition of the denied codes is: 
 
CPT 72070: 
 
Radiologic examination, spine; thoracic 
 
CPT 72040: 
 
Radiologic examination, spine, cervical 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 72020 
and CPT 72040 would not be covered unless reported with modifier 59 Distinct Procedural Service with 
supporting documentation, due to billing CPT 72084 Radiological examination, spine, entire thoracic and 
lumbar, including skull, cervical and sacral spine if performed; minimum of 6 views being billed for same date 
of service. 
 
We looked at this coder's review, the file, and Medicare rules. 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 x-ray services (CPT 72070 and CPT 72040) provided to the enrollee on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of periapical x-rays (D0210) provided on 
June 24, 2020. 
 
You asked the Plan to pay for the complete series of x-rays. You say that you found this provider on the Plan's 
website. You say that you were advised that x-rays and a cleaning would be covered. You also say that you 
received a bill for the services that you received after you were told they would be covered. The Plan denied 
your request. The Plan says the complete series of periapical x-rays 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 
complete series of periapical x-rays (D0210) provided on June 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 9, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these 
services are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that payment may be made for services furnished to 
individuals who are in the custody of police only when the above criteria are met. 
 
We looked at the file and Medicare rules. The enrollee in this case was in custody when the ambulance services 
were provided. The Medicare criteria for coverage of these services provided to an individual in custody have 
not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on 
July 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by a 
non-participating provider. 
 
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 were rendered by a non-participating 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 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 by a non-participating 
provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 12, 2020, through 
June 14, 2020. 
 
You asked the Plan to pay for these services. You say that an acute inpatient hospital admission was medically 
necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee did not meet clinical 
criteria for payment of inpatient hospital care services. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that it was reasonable to believe that an elderly patient with these comorbid conditions with an abnormal 
computed tomography (CT) scan and in need of intravenous pain medication would require two or more 
midnights for admission.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from June 12, 2020, through June 14, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to further reimburse the cost of the hearing aids provided February 13, 
2020. 
 
You asked the Plan to further reimburse the cost of the hearing aids. You say that the medical records indicate 
the service is medically necessary. The Plan denied your request. The Plan says the benefit limit for how much 
they will reimburse for hearing aids has been met. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan provides 
reimbursement for hearing aids only in an amount up to $500. 
 
We looked at the file and the Plan's rules. According to the records provide in the case file, the Plan has 
reimbursed you $500 for the hearing aids. This means that they have provided the maximum reimbursement 
amount available for hearing aids stipulated in their contract. Based on this information, we decided that the 
Plan's rules for further reimbursement for the hearing aids have not been met. Therefore, we decided that the 
Plan does not have to further reimburse the cost of the hearing aids provided February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee from August 28, 2019, 
to November 29, 2019 and billed under codes 85025, 80053, 80061, 84443 and 85027.  
 
You asked the Plan to pay for services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says codes 85025, 80053, 80061, 84443 and 85027 were denied because an 
inappropriate POS code was reported.  
 
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 cannot be paid as 
billed due to an issue with the POS code. Medicare billing criteria were not met. Therefore, we decided that the 
Plan does not have to pay for lab services provided to the enrollee from August 28, 2019, to November 29, 
2019 and billed under codes 85025, 80053, 80061, 84443 and 85027.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on May 9, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided to the enrollee by an out-of-network provider 
on May 9, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided to the enrollee on April 21, 
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 claim submitted does not include an appropriate primary diagnosis code. 
 
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 lacks an appropriate 
primary diagnosis code. Medicare rules for coverage of this service have not been met. Therefore, we decided 
that the Plan does not have to pay for outpatient services provided to the enrollee on April 21, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 17, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
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 services was not filed until July 17, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the services provided on March 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), 
preventive procedure (D1999), endodontic therapy (D3330), and problem focused limited oral evaluation 
(D0140) provided on June 25, 2020. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation, preventive procedure, endodontic 
therapy, and problem focused limited oral evaluation. You say that you cannot control when your teeth start 
acting up, and these services were necessary. The Plan denied your request. The Plan says cone beam CT 
capture and interpretation, preventive procedure, and endodontic therapy are not covered benefits under your 
dental plan. The Plan also says that the problem focused limited oral evaluation exceeds the frequency 
limitation in your benefit 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, cone beam CT capture and 
interpretation, preventive procedure, and endodontic therapy are not among those covered under this benefit. 
The contract clearly states that problem focused limited oral evaluation (D0140) is limited to one procedure per 
plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on June 17, 
2020, and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364), preventive 
 
 
procedure (D1999), endodontic therapy (D3330), and problem focused limited oral evaluation (D0140) 
provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on June 10, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you relay on the hospital to obtain prior 
authorization. The Plan denied your request. The Plan says prior 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 physician services provided on June 10, 2020 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on August 6, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that this should qualify under Covid to 
be refunded the 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 $45 
copayment for provider and professional services at an in-network specialist's office.  
 
You have been asked to pay a $45 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner services, including doctor's office visits" benefit category. The Plan says that only 
copayments for in-network telehealth visits, primary care provider visits or outpatient non-facility based 
behavioral health service are being waived. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office 
visit provided on August 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory test provided on July 9, 
2020. 
 
You asked the Plan to waive the copayment for the laboratory test. You say that you were told there were no 
copayments for PCP's or specialist's until December. 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 $20 
copayment per visit for laboratory tests.  
 
You have been asked to pay $2.25, which is less than the standard $20 copayment for the laboratory test. The 
laboratory test 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 laboratory test provided on July 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on January 3, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan 
says that prior 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 lab services provided on January 3, 2020 by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hysterectomy provided from July 28, 
2020, to July 29, 2020. 
 
You asked the Plan to waive the copayment for the hysterectomy. You say that the surgery was authorized and 
approved. You say that they made you stay overnight and you are appealing the charge. 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 $195 
copayment for surgery services at an in-network outpatient hospital. 
 
You have been asked to pay a $195 copayment for the hysterectomy. The hysterectomy 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 hysterectomy provided 
from July 28, 2020, to July 29, 2020.