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

 
We decided that the Plan does not have to pay for the laboratory services provided on September 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contractual agreement indicating that these services are included in the payment for the dialysis 
services. The Plan denied your request. The Plan says payment for these services is included in the payment to 
the ESRD facility. 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 provided on September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on July 12, 2021. 
You asked the Plan to pay for the services provided. You say that the providers routinely find unexpected 
results. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim at issue lists a place of service as an office. The records show the 
enrollee was in a skilled nursing facility at the time the specimen was obtained. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab testing services provided on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that you need dentures. The Plan denied your 
request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has 
been reached. 
 
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 and dentures are covered once every 5 
plan years, the frequency limit has been reached. The record shows that the Plan paid for dentures that you 
received on December 30, 2021. Therefore, we decided that the Plan does not have to pre-approve a complete 
upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an ankle x-ray and an orthopedic specialist 
office visit provided on December 20, 2021. 
 
You asked the Plan to waive the copayments for an x-ray and a specialist office visit. You say that this was a 
follow up from an injury. You also say it should all be covered. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. The Plan says that the global surgery period ended on 
December 7, 2021. 
 
 
 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 basic imaging service, including x-rays. The Plan contract also says that enrollees must pay a 
$35 copayment for a specialist office visit. 
 
The record shows that the global surgery period ended prior to services on December 20, 2021. The record also 
shows that x-rays are not covered under the global surgery policy. You have been asked to pay a $35 
copayment for an x-ray. An x-ray falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. You have also been asked to pay a $35 copayment for a specialist office visit. A 
specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit 
category. You have been asked to pay a total of $70 ($35 copayment + $35 copayment = $70). 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 copayments for an ankle x-ray and an orthopedic specialist office visit provided on 
December 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing services provided on June 8, 2021.
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been coded correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the genetic testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on November 16, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this exam 
should be considered a necessary preventive and diagnostic exam. You also say that you would like to be 
reimbursed the $69 for this oral exam that prevented the infection from spreading and becoming worse. The 
Plan denied your request. The Plan says this service is not included on your plan's benefit schedule. 
 
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. The only types of oral evaluations that are covered under your dental 
benefit are periodic oral evaluation (D0120) and comprehensive oral evaluation (D0150). Therefore, we 
decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on 
November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on 
December 15, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you asked the facility if the 
cleaning would be cover by your insurance and you were told that it would be covered. You also say that you 
received a claim for $171.00 and cannot afford it. The Plan denied your request. The Plan says this service is 
not a covered expense under your dental plan. The Plan also says that you contacted the Plan on December 7, 
2021 to seek providers and you asked if you were covered for regular cleanings and advised you were covered 
for two regular cleanings per year. No inaccurate information was provided. 
 
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 
complete series of intraoral x-rays (D0210) provided on December 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy, flexible, with biopsy 
(45380) provided on October 20, 2021. 
 
You asked the Plan to waive the copayment for a colonoscopy, flexible, with biopsy. You say that the 
colonoscopy performed was a screening colonoscopy for colorectal cancer and should not be subject to 
copayments or cost shares. You also say this was not a diagnostic colonoscopy. The Plan denied your request. 
The Plan says you were charged the correct cost sharing 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 $375 
copayment for each visit to an ambulatory surgical center for Medicare-covered services.  
 You have been asked to pay a $375 copayment for a colonoscopy, flexible, with biopsy. A colonoscopy, 
flexible, with biopsy falls within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 colonoscopy, flexible, with biopsy (45380) provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional visits or imaging services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve additional visits or imaging services. You say that this care is medically 
necessary. The Plan denied your request. The Plan says additional services beyond the approved second 
opinion consultation will need to be requested again. 
 
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 additional visits or imaging services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve removals of residual tooth roots (D7250) for tooth #'s 5 and 10. 
 
You asked the Plan to pre-approve the removals of residual tooth roots. You say that the caries in subgingival 
will require bone removal for extraction. The Plan denied your request. The Plan says that the information 
submitted does not support the type of extraction that has been requested. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable x-rays for this case. We asked 
for this document, but it was not provided to us. Without this information we cannot determine that the Plan's 
coverage rules support the denial of payment in this case. Consequently, the Plan has not substantiated their 
denial of payment. Therefore, we decided that the Plan has to pre-approve removals of residual tooth roots 
(D7250) for tooth #'s 5 and 10.  
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays (D0230 x 4), and gingival irrigation 
(D4921 x 4) provided on October 25, 2021. 
 
You asked the Plan to pay for the periapical x-rays and gingival irrigation. You say that you have been 
undergoing periodontal maintenance for years. You say that you have had surgery plus scaling and deep 
cleanings for over 20 years. You also say that this should be covered. The Plan denied your request. The Plan 
says periapical x-ray is not listed as a covered service. The Plan says that gingival irrigation is not listed as a 
covered service either. 
 
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 periapical x-rays and gingival 
irrigation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the periapical x-rays (D0230 x 4), and gingival irrigation (D4921 x 4) provided on October 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Ambulance Transportation on October 30, 
2021. 
 
You asked the Plan to waive the copayment for Ambulance Transportation. You say that [Enter appellant's 
argument from appeal letter, e.g., "...you need SNF care."] The Plan denied your request. The Plan says [Enter 
plan denial rationale, e.g., "...rules for SNF care have not been met."] 
 
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 $275 
copayment per ambulance transport for Ambulance Transportation.  
 
 
 
 
 You have been asked to pay a $275 copayment per ambulance transport for Ambulance Transportation. 
Ambulance Transportation falls within the Ambulance 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 Ambulance Transportation on October 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from November 10, 
2021, to November 12, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that the services were previously approved. The Plan 
denied your request. The Plan says providers are required to furnish necessary information to the healthplan 
when requested. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital care provided 
from November 10, 2021, to November 12, 2021. have been met. Specifically, we cannot determine how the 
enrollee came to the servicing provider or whether the services are medically necessary.. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital care provided from November 10, 2021, to 
November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the oral evaluation (D0150), prophylaxis (D1110), 
and complete series x-ray (D0210) provided on October 25, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you were unaware that this dentist 
did not accept Medicare. You also say that you would not have gone to her if you had known. The Plan denied 
your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that 
payment cannot be made to a provider that has opted out of Medicare. 
 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to reimburse you for the oral evaluation (D0150), prophylaxis (D1110), and 
complete series x-ray (D0210) provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve partial upper and partial lower dentures (D5213, D5214). 
 
You asked the Plan to pre-approve partial dentures. You say that your current dentures are broken and 
unusable. The Plan denied your request. The Plan says that partial dentures are covered once every five plan 
years. You previously received partial dentures in September 2018, which were covered by the Plan less than 
five years before this request. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan denied coverage for the dentures because they say you 
previously had dentures provided less than five years ago. No documentation was provided to support that a 
previous claim for partial dentures coded with D5213 and D5214 was paid by the Plan within the last five plan 
years. Therefore, we decided that the Plan has to pre-approve partial upper and partial lower dentures (D5213, 
D5214).  
 
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.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral counseling for obesity (G0447) provided on 
October 22, 2021. 
 
You asked the Plan to pay for behavioral counseling for obesity. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that BMI, coma scale, NIHSS 
codes and categories Z55-Z65 should only be reported as secondary diagnoses. 
 In this case, the claim for behavioral counseling for obesity was billed with the BMI diagnosis code as the 
primary diagnosis which is not appropriate. Based on this information, we decided that Medicare rules for 
coverage of behavioral counseling for obesity have not been met. Therefore, we decided that the Plan does not 
have to pay for behavioral counseling for obesity (G0447) provided on October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on November 1, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says one code must be 
submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The gene testing was billed with multiple codes. If a single procedure is 
performed, only one code with one unit of service may be reported for the procedure. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection by nucleic acid coded 87799 
provided on September 9, 2021. 
 
You asked the Plan to pay for infectious agent detection by nucleic acid. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this code is not covered as 
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, we have confirmed that code 87799 
is a column II code to column I code 87798. 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 infectious agent detection by nucleic acid coded 87799 provided 
on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye exam (92014) provided on 
October 6, 2021. 
 
You asked the Plan to waive the copayment for a medical eye exam. You say that the provider did not submit 
the claim correctly. You also say that you were told that the provider would resubmit the correct claim. The 
Plan denied your request. The Plan says the copayment you are being charged is correct. 
 
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 $45 
copayment for each Medicare- covered exam to diagnose and treat diseases or conditions of the eye.  
 
You have been asked to pay a $45 copayment for a medical eye exam. The records show that you had a 
diagnostic eye exam to treat a condition of the eye. The EOC confirms that $45 is the required copayment for 
this service. 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 medical eye exam (92014) provided on 
October 6, 2021.