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

 
We decided that the Plan does not have to pay for the root canal (D3310) for tooth # 11 provided. 
 
You asked the Plan to pay for the dental service. You say that the service was extremely necessary. You say 
that you were in severe pain for several days while trying to determine what was causing the pain. You say that 
you called several emergency dental offices and were not able to get a return call. You also say that the 
provider determined your root was exposed. The Plan denied your request. The Plan says root canal 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the root canal is 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 pay for the root canal (D3310) for tooth # 11 provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip x-ray rendered on July 13, 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 procedure code 73501 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 73501 and 73502. Code 73501 is a column II code with a 
modifier indicator of 1 when billed with column I code 73502. Code 73501 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the hip x-
ray rendered on July 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you had COVID-19 and the copayment should be waived. 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 ambulance services.  
 
You received ambulance services, from an out-of-network provider. Therefore, you are 
responsible to pay the $250 copayment.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 ambulance services 
provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic shoes and inserts provided to the enrollee on 
June 10, 2020. 
 
You asked the Plan to pay for the diabetic shoes and inserts. You say that this should be paid. The Plan denied 
your request. The Plan says that the billed supply code cannot be verified. 
 
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 for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the diabetic shoes and inserts provided to the enrollee on June 
10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0367) 
provided on June 24, 2020. 
 
You asked the Plan to pay for the dental service. You say that you had surgery. You also say that the cone 
beam CT was the appropriate diagnostic study to evaluate the post-surgical status of the reconstruction, and to 
determine available further treatment options. The Plan denied your request. The Plan says cone beam CT 
capture and interpretation 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 cone 
beam CT capture and interpretation (D0367) provided on June 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the abdomen 
rendered. 
 
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 procedure code 74183 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 74183 and 74182. Code 74183 is a column II code with a 
modifier indicator of 1 when billed with column I code 74182. Code 74183 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
magnetic resonance imaging (MRI) of the abdomen rendered.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on February 17, 
2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 17, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on 
February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from July 25, 2020, to July 
27, 2020. 
 
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that these drugs should 
be covered by the Plan. The Plan denied your request. The Plan says claims for self-administered drugs are 
covered under Medicare Part D. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from July 25, 2020, to July 27, 2020.  
 
Benefits for self-administered drugs under Medicare Part B may be available under Medicare Part D. Contact 
the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you disagree with the charges 
because copayments should be waived due to the pandemic. 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 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
co payment for podiatry services.  
 
Co payments are waived due to the pandemic between May 11, 2020, to September 30, 2020. The podiatry 
services you received , fall outside of the waiver time frame. Therefore, you are responsible to 
pay the $45 co payment.  
 
You have been asked to pay a $45 co payment for podiatry services. Podiatry services fall within the podiatry 
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 co payment for podiatry services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug tests (80307 and G0483) provided 
by an out of network (OON) provider. 
 
You asked the Plan to pay for drug tests. You say that you provided medically necessary services in good faith. 
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 drug tests (80307 and G0483) provided 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provide by an out of network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you did not know you needed a referral. 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 specialist services provide by an out of network 
(OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the glycated hemoglobin (blood sugar) testing rendered. 
 
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 that the testing exceeds the coverage limitation. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the testing exceeds the benefit limit; however, the Plan has 
not provided clear documentation showing when this testing was last performed and paid by the Plan. 
Therefore, we decided that the Plan has to pay for the glycated hemoglobin (blood sugar) testing rendered.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the underarm crutch (E0114) provided, by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the underarm crutch. You say that the durable medical equipment provided was 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 underarm crutch (E0114) provided, by an 
out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you had to return to 
the hospital because you developed an infection.  You say that you should only have to pay the copayment for 
your first admission. The Plan denied your request. The Plan says you were charged this copayment 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 $225 
copayment per day for days 1-6 and $0 for additional days per admission for inpatient hospital care.  
 
You have been asked to pay a $225 copayment per day for days 1-6 and $0 for additional days per admission 
for the inpatient hospital services. This copayment applies per admission, regardless of why additional 
admissions may have been needed. 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 inpatient hospital 
services you received.  
 
Please note that this decision is limited to the inpatient hospital services noted above.  Your appeal letter 
indicated that you were also appealing home health cost sharing.  Please contact your Plan about any appeal 
rights you may have in relation to these services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit (99214) provided. 
 
You asked the Plan to pay for an office visit. You say that this should be covered. The Plan denied your 
request. The Plan says that the allowed amount is unchanged by the diagnosis codes and was previously paid. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the allowed amount was paid on a previous claim, and the 
allowed amount is unchanged by the different diagnosis codes on the claim at issue. However, the paid claim 
included in the case file has a different rendering provider with a different specialty than the provider of the 
service at issue. The Plan has not provided information on why this provider?s services are included in the 
allowed amount of the paid claim. Therefore, we decided that the Plan has to pay for an office visit (99214) 
provided.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical services (52442, 52441) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the surgical services. You say that the urologist you are requesting is the 
only one who provides this type of services. The Plan denied your request. The Plan says they have multiple 
options for in-network providers able to provide the requested 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the surgical services (52442, 52441) to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the physical therapy services. You say that this provider is convenient for 
you because this is where you live and you do not have a car so you can go upstairs to get the physical therapy 
services. The Plan denied your request. The Plan says the services can be provided with an in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services provided to be provided by the out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that you are requesting a 
reconsideration of the Plan's denial as you do not have any other form of transportation to the necessary 
appointment. The Plan denied your request. The Plan says your request exceeds the allowable mileage per one-
way trip. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan?s rules for coverage of routine transportation have not been met. Specifically, your request 
exceeds the allowable mileage per one-way trip. The shortest distance from your home to the provider?s office 
is 60.8 miles. The Plan contract states that each one-way trip must not exceed 50 miles. Therefore, we decided 
that the Plan does not have to pre-approve additional routine transportation mileage (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (97110, 97012 and 98940) provided 
on July 26, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that the service is 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 chiropractic services (97110, 97012 and 
98940) provided on July 26, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe debridementof nails (11721) provided on June 19, 2020 by an out of network (OON) provider.You asked the Plan to pay fordebridement of nails. You say that the services 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 forthe debridement of nails (11721) provided on June 19, 2020 by an out of network (OON) provider.