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

 
We decided that the Plan does not have to pay for an emergency department visit (code 99285) provided on 
June 17, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that the claim was originally submitted 
timely. The Plan denied your request. The Plan says a corrected claim must be receive within one year 
(12 months) from the processed date of the original claim submission. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit was not filed until October 3, 2022. 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 an emergency department visit (code 99285) 
provided on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D4265). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting reconsideration for the 
denial of dental code D4265. The Plan denied your request. The Plan says you are only covered for dental 
services and codes listed in the dental benefits chart. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
biologic materials to aid in soft and osseous tissue regeneration (D4265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty (D7320). 
 
You asked the Plan to pre-approve the dental service. You say that you have never had a dental denial and it is 
necessary to get the requested service done. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because alveoloplasty is not covered by the Plan. 
 
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 requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
alveoloplasty (D7320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional 36 routine transportation trips. 
 
You asked the Plan to pre-approve the additional 36 routine transportation trips. You say that you are appealing 
the denial. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you will have exhausted the Plan maximum benefit for coverage of routine transportation. Specifically, you have used 32 trips and currently have 4 trips remaining for 2023. Therefore, we decided that the Plan does 
not have to pre-approve the additional 36 routine transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on March 01, 2022, to 
March 17, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on March 01, 2022, to March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a complete lower denture (D5731) provided on 
November 10, 2022. 
 
You asked the Plan to pay for the dental service. You say that you verified the dental procedure was covered 
and would have not done it if it was not covered. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
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, certain limitations apply. On 
November 10, 2022, the Plan paid for a reline of the complete upper denture (D5730); therefore, The benefit 
for the reline of the complete lower denture (D5731) was exhausted on the date of service of November 10, 
2022. Therefore, we decided that the Plan does not have to pay for the reline of a complete lower denture 
(D5731) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the transportation ancillary services. 
 
You asked the Plan to pre-approve the transportation ancillary services. You say that you are requesting that 
the Plan covers an additional 18.6 miles to get to your initial appointment and any additional appointments. The 
Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of one-way trips must exceed 50 miles of driving distance trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you the Plan maximum benefit for coverage of 50 miles of driving distance per one-way per would be 
exceeded. Therefore, we decided that the Plan does not have to pre-approve the transportation ancillary 
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an oral evaluation (D0120), intraoral radiographic 
images (D0220), a cleaning (D1110), and the application of fluoride (D1206) provided by an out-of-network 
provider on November 29, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the Plan to reconsider 
charges because you are covered for out-of-network benefits. The Plan denied your request. The Plan says you 
are responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. Also, the denial of payment for the application of fluoride is correct because 
it is not covered by the Plan. 
 
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. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
application of fluoride is not covered under the Plans dental benefit. Therefore, we decided that the Plan does 
not have to pay more for an oral evaluation (D0120), intraoral radiographic images (D0220), a cleaning 
(D1110), and the application of fluoride (D1206) provided by an out-of-network provider on November 29, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray services provided on December 29, 
2022. 
 
You asked the Plan to waive the copayment for x-ray services. You say that you disagree with the copayment. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $35 
copayment for outpatient diagnostic tests/X-ray. 
 
You have been asked to pay a $35 copayment for x-ray services. This item/service falls within the outpatient 
diagnostic tests/X-ray 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 x-ray 
services provided on December 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on November 14, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would 
like this service covered as you were transported to the hospital by your wife. 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 November 14, 2022. 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 response and treatment with no 
transport provided on November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring provided on August 20, 2022. 
 
You asked the Plan to pay for remote monitoring. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for remote monitoring 
provided on August 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DNA gene analysis provided on November 9, 2022, by an 
OON provider. 
 
You asked the Plan to pay for DNA gene analysis. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the enrollee must receive care from a 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 had network providers available who could have provided 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 DNA gene analysis provided on November 9, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary visit provided on October 19, 2022. 
 
You asked the Plan to pay for a domiciliary visit. You say that the assisted living facility is responsible to 
obtain prior authorization for all of their patients. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a domiciliary visit 
provided on October 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for magnetic resonance imaging (MRI) 
provided on October 11, 2022. 
 
You asked the Plan to reduce the copayment for magnetic resonance imaging (MRI). You say that your 
copayment is usually $40. The Plan denied your request. The Plan says this cost sharing was charged 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 $180 
copayment for advanced imaging services. 
 
You have been asked to pay a $180 copayment for magnetic resonance imaging (MRI). This item/service falls 
within the advanced imaging 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 reduce the copayment for 
magnetic resonance imaging (MRI) provided on October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99223 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the 
documentation does not support the billed code. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the billed services. Our reviewer found that 
the enrollee was admitted to the acute hospital for a left carotid endarterectomy. The evaluation and 
management code billed requires a comprehensive history, a comprehensive examination and medical decision 
making of high complexity. However, the medical records submitted did not support a comprehensive history 
and a comprehensive examination. Therefore, the billed code is not supported. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99223 billed for date of service August 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a sleep study provided on August 25, 2022. 
 
You asked the Plan to waive the copayment for a sleep study. You say that this service was incorrectly billed. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $160.45 
for outpatient diagnostic procedure and test in an outpatient facility.  
 
You have been asked to pay $160.45 for a sleep study. This item/service falls within the outpatient diagnostic 
procedure and test in an outpatient facility 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 sleep study provided on August 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service October 4, 
2022. 
 
You asked the Plan to pay for procedure code 70544. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 70544 is bundled into payment for code 70551. 
 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, we have confirmed that code 70544 
is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70544 billed for date of service October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of an impacted tooth (D7220) provided on 
November 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know that is service would not be 
covered under your dental plan. 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 Plans 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 
removal of an impacted tooth (D7220) provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on December 
1, 2022. 
 
You asked the Plan to pay for the dental service. You say that the procedure was recommended by your dentist, 
and you would like to pay the difference in cost between the procedure and a regular cleaning. The Plan denied 
your request. The Plan says the denial of payment for this service is correct, because the periodontal 
maintenance is not covered by the Plan. 
 
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 requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on December 1, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a kidney transplant listing. 
 
You asked the Plan to pre-approve the requested services. You say that you have end stage renal disease related 
to diabetes. The Plan denied your request. The Plan says that you are not medically cleared for a listing. 
 
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 the requested services. Our physician 
reviewer found that you have been deemed a suitable candidate for listing by the transplant center. The listing 
was denied for reasons that are not typical for rejecting for transplant. The transplant centers assessment for 
transplant suitability is valid. It is typical for transplant candidacy be decided by the transplant center. 
Therefore, the requested placement on the kidney transplant list is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve a kidney transplant listing.  
 
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.