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

 
We decided that the Plan does not have to pay for the clinical crown lengthening (D4249) provided on March 
10, 2020. 
 
You asked the Plan to pay for the clinical crown lengthening. You say that from the denial report you 
understand that the treatment is covered as part of an inclusive in the primary treatment, and not as a separate 
benefit. The Plan denied your request. The Plan says this service is not a covered benefit 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 the 
clinical crown lengthening (D4249) provided on March 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on May 
4, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you disagree with the 
charges because you avoided a needle biopsy with the test. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $80 
copayment for diagnostic mammography.  
 
You have been asked to pay a $80 copayment for a diagnostic mammogram. A diagnostic mammogram falls 
within the outpatient hospital services 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 a 
diagnostic mammogram provided on May 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for the wound therapy pump provided from May 12, 
2020, to May 31, 2020. 
 
You asked the Plan to further pay for the services provided. You say that you extended treatment in good faith 
based on the expectation of payment. The Plan denied your request. The Plan says the services are paid on a 
monthly basis. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors pay the fee schedule amounts on a 
monthly rental basis. 
 
We find that the item at issue was paid by the Plan based on the fee schedule for a monthly basis. Therefore, 
we decided that the Plan does not have to further pay for the wound therapy pump provided from May 12, 
2020, to May 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 20, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the claims are being submitted with 
inappropriate home health data. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
 
 
 
 
 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
submitted claim was not billed with a valid HIPPS code. HIPPS code 2CFMT was not effective for the billed 
date of service. Therefore, we decided that the Plan does not have to pay for the home health services provided 
to the enrollee from February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the comprehensive oral evaluation, the 8 
extractions, the bone replacement graft, and the implant service provided from January 23, 2020, to February 
12, 2020, by an out of network dentist. 
 
You asked the Plan to reimburse you for the comprehensive oral evaluation, the 8 extractions, the bone 
replacement graft, and the implant service provided from January 23, 2020, to February 12, 2020, by an out of 
network dentist. You say that the services should be covered. The Plan denied your request. The Plan says 
dental services that you receive out of network 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, dental services that you receive out of 
network are not covered. Therefore, we decided that the Plan does not have to reimburse you for the 
comprehensive oral evaluation, the 8 extractions, the bone replacement graft, and the implant service provided 
from January 23, 2020, to February 12, 2020, by an out of network dentist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood count complete automated and automated 
differential white blood cell count (85025) and comprehensive metabolic panel (80053) provided on October 9, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for blood cell count and comprehensive metabolic panel. You say that the services 
rendered were medically necessary. The Plan denied your request. The Plan says prior authorization must be 
obtained for non-emergent services rendered by an out-of-network provider. 
 
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 blood count complete automated and 
automated differential white blood cell count (85025) and comprehensive metabolic panel (80053) provided on 
October 9, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from March 6, 
2020, to March 30, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan states that the required Q codes were not billed on the claim.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted is lacking the 
required Q codes as stated above in the Medicare rules. Medicare billing criteria for payment of this claim 
have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided 
to the enrollee from March 6, 2020, to March 30, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management (EM) services provided on February 
13, 2020, with reported primary diagnosis code T50.8X5A. 
 
You asked the Plan to pay for the EM services. You say that this has been a valid diagnosis code since 2016 
and should not be the basis for denial. The Plan denied your request. The Plan says that the billed service, 
99204, was denied because it did not include the appropriate primary, first-listed or principal diagnosis. 
 
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. In this case, the Plan indicates that this claim is not payable as the reported 
primary diagnosis can only be used as a secondary diagnosis. However, review of this diagnosis code does not 
support this conclusion. The ICD-10 manual clearly states that "secondary" diagnosis codes, or manifestation 
codes, will either have a "Code First" note or state "in diseases elsewhere classified". In this case, the reported 
diagnosis has neither. The definition is Adverse effect of diagnostic agents, initial encounter. There is nothing 
to indicate that this is should not be used as a primary diagnosis code. As such, we find this denial of payment 
to be unsupported. Therefore, we decided that the Plan has to pay for the evaluation and management (EM) 
services provided on February 13, 2020, with reported primary diagnosis code T50.8X5A.  
 
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvean abdominoplasty.You asked the Plan to pre-approvean abdominoplasty. The Plan denied your request. The Plan says that this procedure is not medically necessary.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 abdominoplasty. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that although diastasis recti correction is typically associated with cosmetic procedures, this case is an exception to this.  The enrollee has a clear functional impairment that has failed conservative management. There is a likelihood that this can be improved with diastasis rectus repair. In addition, the photographs demonstrate a severely abnormal appearance, and thus correction would be considered reconstructive surgery. Therefore, the procedure satisfies Medicare medically necessary criteria.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 abdominoplasty have been met.Therefore, we decided that the Plan has to pre-approvean abdominoplasty.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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from March 29, 
2019, to April 5, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges because you were admitted for a surgery but due to an emergency case you were unable to receive the 
surgery. The Plan denied your request. The Plan says the claims were processed correctly, and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for days 1-6 for inpatient hospital care.  
 
You had an inpatient hospital stay from March 29, 2019, to April 5, 2019. Therefore, you are responsible to 
pay a $250 copayment for days 1-6 (March 29, 2019, to April 3, 2019). $250 (copayment) x 6 (inpatient days) 
= $1,560.  
 
You have been asked to pay the total copayment amount of $1,560 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay from March 29, 2019, to April 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on November 15, 
2019. 
 
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 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 services at issue in this appeal. The Plan did not 
pre-approve the service 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 physician services provided to the enrollee on 
November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on October 12, 2019, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
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 October 12, 2019, 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the occlusal orthotic device (D7880) and the 
personal protective equipment (PPE) due to COVID-19 (D1999) provided on May 19, 2020. 
 
You asked the Plan to reimburse you for the dental items. You say that you need the occlusal orthotic device 
for your tempomandibular joint (TMJ) pain. You say you were advised that the item was medical in nature. 
The Plan denied your request. The Plan says PPE due to COVID-19 is not payable under the supplemental 
benefit. The Plan also says the occlusal orthotic device is medical in nature and not payable under the 
supplemental dental 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 items or services you received are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse 
you for the occlusal orthotic device (D7880) and the personal protective equipment (PPE) due to COVID-19 
(D1999) provided on May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for lab services provided on June 9, 2020. 
 
You asked the Plan to waive the coinsurance for lab services. You say that you assumed this provider was in-
network and received the services as part of your annual wellness exam. The Plan denied your request. The 
Plan says the coinsurance 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 a 45% 
coinsurance for out-of-network lab services.  
 
The allowed amount of the claim is $35.79, resulting in a coinsurance obligation of $16.12 for lab services. Lab 
services fall 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 coinsurance for lab services provided on June 9, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 14, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying 
etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the 
ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, 
followed by the manifestation.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency department visit have not been met. Specifically, the record shows that the claim 
was billed with primary diagnosis code R65.20. This code has a code first note, which means it is a 
manifestation code and must be sequenced after an etiology code. Therefore, we decided that the Plan does not 
have to pay for the services provided on April 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Salivary Pan Cancer Panel rendered on February 25, 
2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says screening tests are not covered. 
 
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 test at issue in this appeal, the Salivary Pan Cancer Panel, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the Salivary Pan Cancer Panel rendered on February 25, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have pay this claim.  
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria were not met. The Plan says that the claim was billed with type 
of bill 0321, which is not payable for per visit billing. As a corrected claim has not been received, this claim 
will be upheld. 
 
 
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 has billing errors 
regarding the type of bill code used. Based on this information, we decided that Medicare rules for coverage 
of this service were not met. Therefore, we decided that the Plan does not have to pay this claim as billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit of an established patient of 25 minutes 
(99214) and presumptive drug test by instrument chemistry analyzers (80307) provided on February 20, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit and drug test. You say that services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services by an out-of-network provider. 
 
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 office visit of an established patient of 25 
minutes (99214) and presumptive drug test by instrument chemistry analyzers (80307) provided on February 
20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided on April 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is a duplicate 
claim. 
 
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 documentation submitted by the Plan does not contain evidence that the 
services in question were billed on a duplicate claim to one previously processed and paid by the Plan. Without 
supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to 
pay for the services provided on April 13, 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.