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

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921). 
 
You asked the Plan to pre-approve the dental service. You say that you are appealing the denied dental 
procedures. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because gingival irrigation 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
gingival irrigation (D4921).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular diagnostic laboratory testing provided on May 
26, 2022. 
 
You asked the Plan to pay for the molecular diagnostic laboratory testing. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the molecular 
diagnostic laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the molecular diagnostic laboratory testing provided on May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment (DME) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve DME. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says care that the enrollee receives from out-of-network providers will not be covered 
unless the care meets one of the three exceptions described in Section 1.2 of this chapter. For information about 
getting out-of-network care when the enrollee has a medical emergency or urgent need for care, please see 
Section 3 in this chapter. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
durable medical equipment (DME) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a diagnostic service consultation (D9310) and therapeutic 
parental drugs (D9612) provided by an out-of-network provider on December 23, 2021. 
 
You asked the Plan to pay for a diagnostic service consultation and therapeutic parental drugs. You say that 
you believe the Plan should pay for this. The Plan denied your request. The Plan says the rendered dental 
services are not covered 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, 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 a 
diagnostic service consultation (D9310) and therapeutic parental drugs (D9612) provided by an out-of-network 
provider on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy visit (90837) provided on May 31, 2022, by an out-of-network (OON) provider.

You asked the Plan to pay for the psychotherapy service. You say that the service should be covered. The Plan denied your request. The Plan says services provided by an out-of-network provider are 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 in this case is not a network provider with the Plan. 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 psychotherapy visit (90837) provided on May 31, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for arm injections provided on March 24, 2022. 
 
You asked the Plan to waive the cost for arm injections. You say that you need the balance waived. 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 $25 
copayment for Physician/Practitioner services, including doctors office visits, and 20% coinsurance for 
Medicare Part B prescription drugs. The allowed amount of this drug or item is $790.78, resulting in a 
coinsurance amount of $158.15 ($790.78 x 20% = $158.15) + $25 office visit copay = $183.16.  
 
You have been asked to pay a $183.16 cost share for arm injections. This item/service falls within the 
Physician/Practitioner services, including doctors office visits and Medicare Part B prescription drugs 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 cost for arm injections provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on June 10, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. 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 $370 
copayment for outpatient surgery/Medicare-covered surgery.  
 
You have been asked to pay a $370 copayment for an outpatient surgery. However, you are only being asked to 
pay $299.25 which is less than the required amount. This item/service falls within the outpatient 
surgery/Medicare-covered 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 on June 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 19, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you have to have multiple 
procedures, and this is adding up. 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 $100 
copayment for Outpatient procedures and services. 
 
You have been asked to pay a $100 copayment for outpatient surgery. This item/service falls within the 
Outpatient procedures and services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan.  Therefore, we decided that the Plan does not have to waive the copayment for 
outpatient surgery provided on August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for advance care planning (99497) billed for date of service 
April 28, 2022. 
 
You asked the Plan to pay for advance care planning. You say that the service at issue has been billed correctly 
for payment. The Plan denied your request. The Plan says payment for code 99497 is included in the payment 
for code 99233. 
 
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 99497 is: Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate.  
We asked our coder 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 advance care planning. Our reviewer says that the procedure 
code at issue does not meet criteria for payment. Our reviewer found that the medical documentation does not 
support the use of procedure code 99497 to be billed above and beyond the evaluation/management for the day. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of advance care planning have not been met. Therefore, we decided that the Plan 
does not have to pay for advance care planning (99497) billed for date of service April 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. In addition, panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. The rules also say that if one laboratory procedure evaluates multiple genes using a next generation 
sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing 
procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary 
laboratory analysis code. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Also, this was an NGS panel 
that was not billed with a single panel code as required. Therefore, we decided that the Plan does not have to 
pay for lab services provided on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 1, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the member must receive care from a network provider 
or it will not be covered except for urgent/emergency care, get approval to see an out-of-network doctor, or 
kidney dialysis services from a Medicare-certified dialysis facility outside the Plans service area. In this case, 
prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan 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 subsequent nursing facility care provided on July 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you need the dentures due to an accident. 
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. The record 
shows your benefit for the requested item or service was exhausted on date of service January 4, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a 
mandibular partial denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided from May 17, 
2022, to May 30, 2022. 
 
You asked the Plan to waive the copayment for ambulance 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 $250 
copayment for ambulance services.  
 
You have been asked to pay a $250 copayment for ambulance services. The total amount you are being asked 
to pay is $500. ($250 x 2 = $500). This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided from May 17, 2022, to May 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient hospital care. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was approved for a total 
left knee arthroscopy and will need inpatient admission after surgery. The Plan denied your request. The Plan 
says there is no documentation provided to support the expectation the enrollee will require a greater than 2 
midnight stay. 
 
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 admission are met in this case. Our 
physician reviewer found the enrollee is scheduled/approved for a total left knee arthroscopy. The record does 
not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights. 
 
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 acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on July 28, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. 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 $10 
copayment for each covered visit or consultation in an outpatient location with your PCP or other primary care 
provider. Covered services include medically-necessary medical care or surgery services furnished in a 
physicians office, certified ambulatory surgical center, hospital outpatient department, or any other location. 
 
You have been asked to pay a $10 copayment for office visit. This item/service 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 office visit on July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided 
on July 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed this service. 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. The record 
shows your benefit for the requested item or service was exhausted on date of service March 10, 2022. 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) 
provided on July 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete intraoral x-ray series (D0210), an unspecified 
preventive procedure (D1999), and gingival irrigation in the upper and lower left quadrants (D4921) provided 
on May 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that your new dental office told you that your 
insurance would cover your services. The Plan denied your request. The Plan says an unspecified preventive 
procedure (D1999) and gingival irrigation (D4921) are not covered by your supplemental dental benefits. The 
Plan also says that your benefit for a complete intraoral x-ray series (D0210) 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, an unspecified preventive procedure 
and gingival irrigation are not among those covered under this benefit. The record shows your benefit for a 
complete intraoral x-ray series was exhausted on date of service September 9, 2020. Therefore, we decided that the Plan does not have to pay for a complete intraoral x-ray series (D0210), an unspecified preventive 
procedure (D1999), and gingival irrigation in the upper and lower left quadrants (D4921) provided on May 18, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and a coinsurance for basic radiological 
services and a wrist hand orthosis provided on August 17, 2022. 
 
You asked the Plan to waive the copayment and a coinsurance for basic radiological services and a wrist hand 
orthosis. You say that you feel the cost share should be covered. 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 $15 
copayment for in-network outpatient hospital services/basic radiological services and a 20% coinsurance for in-
network Prosthetic devices and related supplies.  You have been asked to pay a $15 copayment for basic radiological services and a 20% coinsurance for a wrist 
hand orthosis. The total allowed amount for the wrist hand orthosis is $46.27. You are being asked to pay $9.25 
($46.27 x 20% = $9.25). The total amount you are being asked to pay is $24.25 ($15 + $9.25 = $24.25). 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 and a coinsurance for basic radiological services and a wrist 
hand orthosis provided on August 17, 2022.