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

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), a periapical x-ray 
(D0220), endodontic therapy on tooth #16 (D3330), and does not have to pay for an intraorifice barrier 
(D3911) and cone beam imaging (D0364) provided on April 5, 2022. 
 
You asked the Plan to pay more for an evaluation, x-ray, and endodontic therapy, and to pay for a barrier and 
imaging. You say that you are requesting reimbursement for the remaining amount of $1,151.50. 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. The Plan also says that an 
intraorifice barrier (D3911) and cone beam imaging (D0364) are not covered by your supplemental dental 
benefits. 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, an intraorifice barrier and cone beam 
imaging are not among those covered under this benefit. You have been asked to pay the difference between 
the out-of-network providers charges and the Plans payment for an evaluation, x-ray, and endodontic therapy. 
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 pay more for a limited oral evaluation (D0140), a periapical x-ray 
(D0220), endodontic therapy on tooth #16 (D3330), and does not have to pay for an intraorifice barrier 
(D3911) and cone beam imaging (D0364) provided on April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 31, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and the electrocardiogram (ECG) provided on 
April 8, 2022, and April 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and an ECG. You say that your primary care provider ordered the 
test, and this service should be approved. The Plan denied your request. The Plan says the rendering provider is 
an OON provider, and it was confirmed with the enrollee's primary care provider they did not refer the enrollee 
to the OON 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 an office visit and the electrocardiogram (ECG) 
provided on April 8, 2022, and April 10, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic services provided on April 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for diagnostic services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 diagnostic services provided on April 5, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 12, 2021, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the claim 
denial. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 an office visit provided on February 12, 2021, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99204) provided on 
December 6, 2021. 
 
You asked the Plan to waive the copayment for the physician service. You say that the enrollee was not able to 
get into their regular doctor. You say that you went to a walk-in clinic. You say that the enrollee's doctor visits 
have a $0 copayment. You also say that this should be covered as a doctor appointment instead of a specialist 
appointment. The Plan denied your request. The Plan says the claim processed 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $40 copayment for Specialist's Office.  
 
The enrollee has been asked to pay a $40 copayment for the physician service. The physician service falls 
within the Specialist's Office 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. The record shows that the service you received was performed at a walk-in 
clinic and not your primary care physicians office thus, the Specialists Office copayment was applied correctly. Therefore, we decided that the Plan does not have to waive the copayment for the office visit (99204) 
provided on December 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 testing kits purchased on February 5, 
2022, to February 15, 2022. 
 
You asked the Plan to pay for these services. You say that a reimbursement form is available on the Plan's 
website. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. The rules say 
that services must be furnished by a Medicare-certified provider. 
 
The file shows that you purchased at-home COVID-19 test kids from a provider not certified by Medicare. 
Coverage for these tests is provided by Original Medicare, not the Plan. The notice on the Plans website 
applies to members of a different program and not the Plans Medicare program. Therefore, we decided that the 
Plan does not have to pay for the at-home COVID-19 testing kits purchased on February 5, 2022, to February 
15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 test provided on February 18, 2022. 
 
You asked the Plan to pay for a COVID-19 test provided. The Plan denied your request. The Plan says 
COVID-19 testing for public health surveillance, employment purposes, and other testing not intended for 
individualized diagnosis or treatment of Covid-19 is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the routine physical checkup exclusion applies to 
examinations required by third parties such as insurance companies, business establishments, or Government 
agencies. 
 
We looked at the file and Medicare rules. Medicare says that the routine physical checkup exclusion applies to 
examinations required by third parties such as insurance companies, business establishments, or Government 
agencies. Therefore, we decided that the Plan does not have to pay for a COVID-19 test provided on  
February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sigmoidoscopy provided on February 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the sigmoidoscopy. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
sigmoidoscopy. We found no exception that would require the Plan to pay for the sigmoidoscopy. The records 
provided for review do not show that the sigmoidoscopy was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the sigmoidoscopy provided on February 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no specific indication provided to support the request for bone marrow 
aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to 
support the use of bone marrow aspirate for this enrollees medical condition as discussed above. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the requested bone marrow aspirate, in this case, is not 
medically reasonable or 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11721 billed for date of service February 1, 
2022. 
  You asked the Plan to pay for procedure code 11721. You say that the physician provided medically necessary 
services and the services meet professionally recognized standards of healthcare. You say that the claim should 
be processed for payment. The Plan denied your request. The Plan says payment for code 11721 is bundled into 
payment for code 11055. 
 
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 11721 
is a column II code to column I code 11055. 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 11721 billed for date of service February 1, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 3, 2020. 
 
You asked the Plan to pay for an office visit. The Plan denied your request. The Plan says per CMS guidelines 
10.6.2 the provider has to submit within one year from the date of the initial determination. 
 
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 an office visit was not filed until March 2, 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 office visit provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 9, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing the denial of the claim and request 
the claim be reprocessed for payment. The Plan denied your request. The Plan says the out-of-network services 
were not authorized. 
 
 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 an office visit provided on February 9, 2022, by an 
OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 home test kits purchased through an e-commerce 
supplier on January 4, 2022. 
 
You asked the Plan to pay for COVID-19 home test kits. You say that you received a signed letter from the 
Plan saying that COVID-19 home test kits paid for out-of-pocket prior to February 15, 2022, would be eligible 
for reimbursement. The Plan denied your request. The Plan says COVID-19 home test kit coverage applies to 
eligible tests purchased on or after February 1, 2022, through the end of the federal public health emergency or 
December 31, 2022, whichever is earlier. The Plan says the tests you purchased are not eligible for 
reimbursement because the benefit was not covered at the time of purchase. Additionally, the Plan says your 
tests were purchased through an e-commerce supplier, which is not a valid supplier for coverage of this benefit. 
 
The Plan must follow Medicare rules. The rules say that health plans were given the option to cover COVID-19 
home testing kits as a supplemental benefit but were not required to do so by Medicare. The Plan 
communicated to enrollees that this testing would be covered as a supplemental benefit, free of charge, after 
February 1, 2022. Furthermore, Medicare began providing coverage of COVID-19 home testing kits starting on 
April 4, 2022. Your purchase was made prior to both of these dates. Therefore, we decided that the Plan does 
not have to pay for COVID-19 home test kits purchased through an e-commerce supplier on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the claim should be paid because it is for an office 
visit and the enrollee lives within the vicinity. The Plan denied your request. The Plan says that the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 an office visit provided on April 12, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 6, 2021, to December 9, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee strongly meets the 
medical necessity criteria for an inpatient level of care. The Plan denied your request. The Plan says the 
enrollee was approved for ambulatory surgery. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that plans for episcleral plaque brachythrerapy were made and approved. This is a 
request for hospital admission related to this procedure. However, based on the relative low risk of this 
procedure and the patient not having any documented unstable conditions, hospital admission is not expected to 
be needed. There was no suggestion based on the provided documentation that this patient would require 
hospital services that would likely cross 2 midnights related to this ambulatory procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from December 6, 2021, to 
December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 14, 2020. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 14, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 4, 2021. 
 
You asked the Plan to pay for the physician's services. You say that the member informed the provider's office 
that she was covered under Medicare. The Plan denied your request. The Plan says the services were not urgent 
or emergent and the services could have been rendered by a Plan participating 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 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 physician's services provided on November 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service November 5, 
2020. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99291 is bundled into payment for code 36556.  
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 99291 
is a column II code to column I code 36556. 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 99291 billed for date of service November 5, 
2020.