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

 
We decided that the Plan does not have to pay for the laboratory services 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 the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive metabolic panel testing provided on March 
27, 2020. 
 
You asked the Plan to pay for lab test. You say that you are appealing. The Plan denied your request. The Plan 
says the denial of payment for this service is correct, because this testing is not a Medicare benefit for the 
diagnosis listed and was performed for screening purposes. 
 
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, lab test, 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 
comprehensive metabolic panel testing provided on March 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services rendered on June 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 the services are not covered. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
62350. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the assistant surgeon services rendered on June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the provisional splinting (D4321) provided. 
 
You asked the Plan to pay for the provisional splinting. 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 
provisional splinting (D4321) provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 12, 2019. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 genetic testing at issue in this appeal 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 genetic 
testing provided on October 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share charged for ambulance transport provided. 
 
You asked the Plan to waive the copayment for this transport. You say that you did not ask for this transport 
and should not have to pay for it. The Plan denied your request. The Plan says the provider will be paid for this 
transport minus the $250 contractual copayment. 
 
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 $250 
copayment for ambulance transport.  
 
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 cost share charged for ambulance transport provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the opthalmological services (92014, 
92015) provided on August 20, 2020. 
 
You asked the Plan to waive the copayment for the opthalmological services. You say that you disagree with 
the copayment as charged. The Plan denied your request. The Plan says the copayment applied correctly in this 
case. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 40$ 
copayment for diagnostic eye exam.  
 
You have been asked to pay a $40 copayment for the opthalmological services. The services provided fall 
within the diagnostic eye exam 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 opthalmological services (92014, 92015) provided on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) provided. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the documentation did not support the services billed. 
 
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 code 99291 is critical care visit of 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not detail how 
much time was specifically spent on this service. Based on this information, we decided that Medicare rules for 
coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to 
pay for critical care services (99291) provided.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided. 
 
You asked the Plan to waive the copayment for emergency care. You say that you should not owe a copayment 
because you went to the emergency room due to COVID-19. 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 $65 
copayment for emergency care.  
 
You received emergency care. Emergency care is not included in the waiver of cost-sharing 
due to COVID-19. Therefore, you are responsible to pay the $65 copayment.  
 
You have been asked to pay a $65 copayment for emergency care. Emergency care falls within the emergency 
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 emergency care provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment testing (81407, 81408) 
provided June 9, 2020. 
 
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that the service was 
medically necessary. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
risk assessment panels, except the basic lipid panel.  
 
We looked at the file and Medicare rules. The cardiovascular testing performed is not covered under Medicare. 
Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment 
testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular risk 
assessment testing (81407, 81408) provided June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 14, 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 the services were not urgent or emergent and were rendered by an out-of-area provider 
without prior authorization. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. The file shows that the services were for a routine annual exam and 
were not urgent or emergent in nature. Based on this information, we decided that Medicare rules for coverage 
of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 64634 provided on June 17, 
2020. 
 
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 64634 is destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint 
(List separately in addition to code for primary procedure). 
 
We find that CPT code 64634 is not supported in the medical record. Specifically, the documentation submitted 
do not support a destruction of two additional levels cervical or thoracic was performed. The submitted 
documents indicate that a destruction by neurolytic agent was only performed at a total of two cervical facet 
levels (i.e. C3-C4 and C4-C5). Therefore, the billed service cannot be verified. Based on this information, we 
decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided 
that the Plan does not have to pay for the injection services coded 64634 provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
June 15, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. 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 subsequent nursing facility care (99308) 
provided on June 15, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the evaluation of physical therapy (97163) provided on August 24, 2020.
You asked the Plan to waive the copayment for the evaluation of physical therapy. You say that you would like the copayment refunded. The Plan denied your request. The Plan says the copayment applied correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for outpatient rehabilitation services. The enrollee has been asked to pay a $40 copayment for the evaluation of physical therapy. The service provided falls within the outpatient rehabilitation services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the evaluation of physical therapy (97163) provided on August 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided. 
 
You asked the Plan to pay for oxygen equipment. You say that you were misled by the seller who assured you 
that insurance did not cover this item. The Plan denied your request. The Plan says the denial of payment for 
this item is correct, because this request for reimbursement was not submitted within the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for oxygen equipment was not filed. 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 oxygen equipment provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the abdomen. 
 
You asked the Plan to pre-approve MRI. You say that you have had too many Computed Tomography (CT) 
scans which is why this MRI was requested. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because research has shown that you would be better evaluated with a 
Computed Tomography (CT) scan with contrast. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that you do not 
meet the Medicare criteria for the requested MRI. Our physician reviewer found you have a history of 
pancreatic cancer and underwent surgery in 2009. You have had chronic abdominal pain and a Computed 
Tomography (CT) scan did not identify a cause for the pain. The documentation does not support that this MRI 
is medically reasonable and necessary for you at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Magnetic Resonance Imaging (MRI) of the abdomen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953), 
the initial 15 minutes of conscious sedation (D9239), and the additional 15 minutes of conscious sedation 
(D9243 x 2) provided. 
 
You asked the Plan to pay for the dental services. You say that the services you received may be covered under 
your medical plan. The Plan denied your request. The Plan says the services you received are dental in nature. 
The Plan says that the bone replacement graft is not listed as a covered service. The Plan says conscious 
sedation is not listed as a covered service either. The Plan says dental services covered under your medical 
coverage must be based on accidental injuries. The Plan also says these services are not an accidental issue. 
 
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 services you received are not 
among those covered under this benefit. Additionally, the services you are asking the Plan to pay for involve 
the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your 
 
 
teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the 
Plan does not have to pay for the bone replacement graft for ridge preservation (D7953), the initial 15 minutes 
of conscious sedation (D9239), and the additional 15 minutes of conscious sedation (D9243 x 2) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the finger orthosis (L3933) provided on June 8, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for finger orthosis. 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 finger orthosis (L3933) provided on June 8, 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 specialist visits provided. 
 
You asked the Plan to waive the copayment for specialist visits. You say that you disagree with the specialist 
charges because your primary care provider was no longer practicing so you found a new physician. 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 $40 
copayment for specialist visits. 
 
You had an office visit. The record shows that the physician you saw was not listed as your 
primary care provider. Therefore, you are responsible to pay the $40 copayment.   
 
You had an office visit. The record shows that the physician you saw was not listed as your 
primary care provider. Therefore, you are responsible to pay the $40 copayment.   
 
The total amount you owe is: $80. 
 
You have been asked to pay the total copayment amount of $80 for specialist visits. Specialist visits fall within 
the physician/practitioner services, including doctor's office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for specialist visits provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4267) and problem focused 
limited oral evaluation (D0140) provided from July 27, 2020, to August 6, 2020. 
 
You asked the Plan to pay for the guided tissue regeneration and problem focused limited oral evaluation. You 
say that during the quarantine your tooth cracked and then crumbled. You also say that you needed this tooth 
removed before it became infected. The Plan denied your request. The Plan says guided tissue regeneration is 
not a covered benefit 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, guided tissue regeneration is not 
among those covered under this benefit. The contract also 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 July 13, 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 guided 
tissue regeneration (D4267) and problem focused limited oral evaluation (D0140) provided from July 27, 2020, 
to August 6, 2020.