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

We decided that the Plan does not have to pay for the computed tomography provided on May 4, 2021.
You asked the Plan to pay for the computed tomography. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services must be submitted to the enrollee's
primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for the computed tomography until the primary insurer has denied the claim for these services. Therefore, we
decided that the Plan does not have to pay for the computed tomography provided on May 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of
service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs and outpatient hospital services
provided on April 20, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were brought to the hospital in
extreme medical condition. You say that you were immediately given steroids and antibiotics upon arrival. You
say that you have not paid the medication part of the bill. You also say that you believe they should be paid
either by the medical insurance or Part D of your coverage. The Plan denied your request. The Plan says the
drugs you received are considered self-administered. The Plan says that self-administered drugs are not paid by
Medicare when submitted on outpatient claims.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs and
outpatient hospital services provided on April 20, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on May 12, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that it is impossible to obtain prior authorization
and you should not be penalized. 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
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the laboratory work provided on May 12, 2021, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided January 7, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
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 CPT code G0483 is not supported in the medical record. Specifically, the place of service on the
claim form (81- laboratory) does not match the place of service detailed in the records (11- office setting).
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 lab services (G0483) provided January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal
implants (D6010 x2), two prefabricated abutments (D6056 x2), and two abutment supported porcelain fused to
metal crowns (D6060 x2).
You asked the Plan to pre-approve the endosteal implants, prefabricated abutments, and abutment supported
porcelain fused to metal crowns. You say that you have had multiple bridges and they have all fallen out of
your mouth. You also say that you need these services urgently. The Plan denied your request. The Plan says
these 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 Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two
surgical placements of implant bodies: endosteal implants (D6010 x2), two prefabricated abutments (D6056
x2), and two abutment supported porcelain fused to metal crowns (D6060 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from
June 21, 2021, to June 29, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you did not know
that this provider was out-of-network. The Plan denied your request. The Plan says you have been 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 $250 per
day for days 1-7 and $0 per day after day 7 for each inpatient stay.
The record shows you were in an in-network hospital from June 21, 2021, to June 29, 2021. Therefore, you
have been asked to pay $250 per day for the first seven days of inpatient hospital services. The total for your
stay is $1750 ($250 copayment x 7 days = $1750). Inpatient hospital services fall within the Inpatient Hospital
Care benefit category. This means that you have been asked to pay the correct amount based on your contract
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services
provided from June 21, 2021, to June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541,
87581, 87634, 87640, 87798, 87500, 87641) provided August 4, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
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 CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798, 87500, &
87641 are not supported in the medical record. Specifically, the place of service on the claim form (81,
laboratory) does not match the place of service detailed in the records (11, office setting). 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 lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581,
87634, 87640, 87798, 87500, 87641) provided August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement partial dentures.
You asked the Plan to pre-approve replacement partial dentures. You say that even though you received
partials, they do not work. You say that your partials are non-functioning because they were improperly made,
and replacements are medically necessary. The Plan denied your request. The Plan says 60 months have not
passed since you received dentures.
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, you also have a maximum benefit of
replacement dentures every 60 months. It has not been 60 months since you last received partial dentures.
Therefore, we decided that the Plan does not have to pre-approve replacement partial dentures
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that the lower partial you received
on May 14, 2018 is so poorly made that after numerous attempts to fix it, it is affecting your ability to eat and
talk. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, mandibular partial denture (D5214) is
limited to one procedure every five plan years. The record shows that you received a mandibular partial denture
(D5214) on May 14, 2018 and your mandibular partial denture (D5214) benefit has been exhausted. Therefore,
we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extremity veins coded 93971 provided on
September 5, 2021.
You asked the Plan to pay for the duplex scan of extremity veins. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately
payable.
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 93971
for the duplex scan of extremity veins is a column II code to column I code 93970. 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 the duplex scan of extremity
veins coded 93971 provided on September 5, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for a specialist physician visit provided on
July 23, 2021.
You asked the Plan to reduce the copayment for the specialist physician visit. You say that you do not
understand why you pay a $10 copayment for primary care and a $40 copayment for specialty care. The Plan
denied your request. The Plan says you have been 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 $40
copayment for each specialist visit.
You have been asked to pay a $40 copayment for the specialist physician visit. Specialist physician visits fall
within the Physician/Practitioner Services Including Doctor's Office Visits benefit category. This means that
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to reduce the copayment for a specialist physician visit provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953)
for tooth # 19.
You asked the Plan to pre-approve the dental service. You say that this service is medically necessary. The
Plan denied your request. The Plan says bone replacement graft for ridge preservation is not listed as a covered
service.
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 bone replacement graft is
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
bone replacement graft for ridge preservation (D7953) for tooth # 19.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a tooth extraction (D7210) provided on June 23,
2021.
You asked the Plan to reimburse you for a tooth extraction. You say that you urgently had to have a tooth
extracted and you were not aware that you did not have dental coverage. You also say this is a financial burden
for you. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for
a tooth extraction (D7210) provided on June 23, 2021.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for an emergency department visit provided on May 5,
2021.
You asked the Plan to waive the copayment for the emergency department visit. You say that you should not be
charged a copayment. You say that this should all be considered one procedure. The Plan denied your request.
The Plan says that you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $120 copayment for each emergency room visit. The
contract also says that if you are admitted to the hospital within 24 hours, you do not have to pay your share of
the cost for emergency care.
The Plan says you must pay a $120 copayment for each emergency room visit for the emergency department
visit. Based on the Plan contract, however, you cannot be asked to pay more than more than $0 for emergency
care if you are admitted to the hospital within 24 hours. The record shows that you were admitted within 24
hours of your emergency department visit. Therefore, we decided that the Plan has to waive the copayment for
an emergency department visit provided on May 5, 2021.
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 pre-approve a comprehensive oral evaluation (D0150), and deep
cleaning (D4341) to be performed by a periodontist.
You asked the Plan to pre-approve the dental services. You say that you were advised by your general dentist
that the hygienist was unable to perform the deep cleaning. You say that you have 6 millimeter pockets and
bone loss. You also say that your general dentist referred you to see a periodontist for the services. The Plan
denied your request. The Plan says dental services must be performed by a participating general dentist. The
Plan also says that dental service to be performed by a periodontist are not covered.
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 service to be performed by a
periodontist are not among those covered under this benefit. Therefore, we decided that the Plan does not have
to pre-approve a comprehensive oral evaluation (D0150), and deep cleaning (D4341) to be performed by a
periodontist.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July
22, 2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were told there
would be no charge. The Plan denied your request. The Plan says you have been 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 $50
copayment for each one-way ambulance trip.
You have been asked to pay a $50 copayment for the ambulance transport. The ambulance transport 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
the ambulance transport provided on July 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541,
87581, 87634, 87640, 87798) provided August 24, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
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 CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, and 87798 are not
supported in the medical record. Specifically, the place of service listed on the claim form (81, laboratory) does
not match the place of service detailed in the records (31, skilled nursing facility). 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 lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634,
87640, 87798) provided August 24, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on July 6, 2021, by an OON
provider.
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. You say you
conducted the test ordered by the referring physician in good faith. 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
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to
pay for the drug testing provided on July 6, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).
You asked the Plan to pre-approve the occlusal guard. You say that you need the occlusal guard because you
grind your teeth at night. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an
occlusal guard (D9944).