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

 
We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
hospital on June 9, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you should only have a $50 copayment. 
The Plan denied your request. The Plan says the correct copayment has 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 $100 
copayment for outpatient diagnostic tests/in-network/diagnostic tests/outpatient hospital.  
 
You have been asked to pay $93.50 which is less than your copayment amount of $100 for an x-ray. An x-ray 
falls within the outpatient diagnostic tests/in-network/diagnostic tests/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 an x-ray provided by a participating hospital on June 9, 
2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the substance abuse evaluation provided on December 13, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for substance abuse evaluation. You say that the member did not provide you with a 
Medicare ID card to be able to request prior authorization. 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 substance abuse evaluation provided on 
December 13, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on July 10, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you were unaware that you 
would have this copayment. The Plan denied your request. The Plan says the correct copayment has 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 $200 
copayment for outpatient surgery.  
 
You have been asked to pay a $200 copayment for an outpatient surgery. The services that were provided are 
considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls 
within the outpatient surgery 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 
outpatient surgery provided by a participating provider on July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor supplies and accessories 
provided from January 31, 2020, through March 31, 2020. 
 
You asked the Plan to pay for the continuous glucose monitor supplies and accessories. The Plan denied your 
request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
continuous glucose monitor supplies and accessories. We found no exception that would require the Plan to pay 
for these items. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor 
supplies and accessories provided from January 31, 2020, through March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99213) 
provided on October 16, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you would 
like this claim reprocessed and approved for payment. 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 established patient office or other outpatient 
visit (99213) provided on October 16, 2019, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation (D0140) and extractions 
(D7210) provided on April 23, 2020. 
 
You asked the Plan to pay more for the limited oral evaluation (D0140) and extractions (D7210). You say that 
you were informed you would only pay 50% of the billed amount. You say that this should be covered at a 
higher amount since you were referred by an in-network dentist. 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, The Plan is only obligated to pay the 
allowed amount for the limited oral evaluation and 50% of the allowed amount for each extraction. You are 
responsible for any amount greater than the payment made by the Plan. Therefore, we decided that the Plan 
does not have to pay more for the limited oral evaluation (D0140) and extractions (D7210) provided on April 
23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on May 12, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you currently have most of your teeth. You say 
that you are trying to keep them. You also say that your dentist advised you need a cleaning every 3 months 
because you build tartar quickly. The Plan denied your request. The Plan says no more than 1 periodontal 
maintenance procedure or cleaning is permitted within any 6 month period. The Plan also says that the 
frequency limit has been exceeded. 
 
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 frequency limit of 1 periodontal 
maintenance procedure or cleaning in a 6 month period has been exceeded. The record shows that you had a 
regular cleaning on January 24, 2020. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician services provided by a 
participating provider on May 7, 2020. 
 
You asked the Plan to waive the copayment for physician services. You say that you do not agree with this 
copayment. The Plan denied your request. The Plan says the correct copayment has 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 $20 
copayment for physician/practitioner services/primary care visit.  
 
You have been asked to pay a $20 copayment for physician services. Physician services fall within the 
physician/practitioner services/primary care visit 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 physician services provided by a participating provider on May 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on May 27, 
2020. 
 
You asked the Plan to pay for digital breast tomosynthesis. You say that this code is supported in the records. 
The Plan denied your request. The Plan says this code is not valid for Medicare. 
 
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 77062 is not supported in the medical record. Specifically, this code has a status 
indicator of I. Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of digital breast tomosynthesis have not been met. 
Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77062) provided on 
May 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology procedure. 
 
You asked the Plan to pay for diagnostic mammography (77066) and screening digital breast tomosynthesis, 
bilateral (G0279) provided June 11, 2020. You say that the enrollee had multiple exams on this date of service. 
The attached reports to support level of service. Please reconsider for processing. The Plan denied your request. 
The Plan says the claim line exceeded the MUE value. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT codes 77066 and G0279 is 1. You billed for 2 units of this code, exceeding the 
MUE. Based on this information, we decided that Medicare rules for coverage of diagnostic mammography 
(77066) and screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary 
procedure) (G0279) have not been met. Therefore, we decided that the Plan does not have to pay for the 
radiology procedure..
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6240) for teeth # 5 and 7, and retainer crowns 
(D6750) for teeth # 4, 6 and 8. 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says multi-unit fixed bridges replacing posterior and anterior teeth are considered 
beyond the scope of the policy benefit. The Plan also says that the requested bridge is not medically necessary. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the requested services do not meet the Dental Plan's criteria for coverage.  
 
 
Our physician reviewer found the provided documentation indicates that multiple maxillary posterior teeth are 
missing. The reviewer found that coverage for a fixed bridge is considered if replacing anterior teeth when no 
posterior teeth are missing. Therefore the reviewer found that the requested services do not meet the criteria for 
coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve pontics (D6240) for teeth # 5 and 7, and retainer crowns (D6750) for teeth # 4, 6 and 8.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 28, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that the visit did not help you and 
you disagree with the charges. 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 $35 
copayment for each specialist visit.  
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls 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 a specialist visit provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided. 
 
You asked the Plan to pay for the outpatient visit. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require 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 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 an outpatient visit provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on April 21, 2020 by an out of network (OON) provider.You asked the Plan to pay forlaboratory services. 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 andpre-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 laboratory services provided on April 21, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 9, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
laboratory services. 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 laboratory services provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated post and core (D2954) provided on June 22, 
2020. 
 
You asked the Plan to pay for the prefabricated post and core (D2954). You say that the tooth needed the post 
and core to retain the crown. You say that the claim needs to be paid. The Plan denied your request. The Plan 
says the service is only covered in conjunction with a crown. 
 
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 Plan also requires the prefabricated 
post and core be performed with a crown. The records show that a crown was not performed with the post and 
core. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core (D2954) 
provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on June 2, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 a domiciliary, rest home visit provided on June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 30, 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the requested CPT codes are not supported in the medical record. Specifically, the records do not 
show that the lab services were performed on a blood specimen. The records show that a urine specimen was 
collected. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 30, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: home with outpatient 
therapy if needed. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for a cerebrovascular accident. Medical problems are stable. There are no identified problems that 
need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.