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

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on 
February 16, 2022. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that this should be 
covered under your wellness plan. 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 
$125.68 copayment for diagnostic procedures or tests at a network outpatient facility. 
 
You have been asked to pay a $125.68 copayment for the diagnostic mammogram. This item/service falls 
within the diagnostic procedures or tests at a network outpatient facility benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. The file shows the mammogram was 
done due to concerns of brown markings on the breast. This makes the test diagnostic. Since the allowed 
amount of $125.68 is less than the $160 copayment per the EOC, you are only responsible for the lesser amount. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic 
mammogram provided on February 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 
29, 2022, to April 01, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be 
responsible to pay this. 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 $1,140 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,140 copayment for inpatient hospital care. This item/service falls 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 care provided on March 29, 2022, to April 01, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 
25, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were unable to stand and 
had to call for help 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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for ambulance services. This item/service 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 services 
provided on October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remaining 10 units of procedure code 88341 billed for 
date of service May 19, 2022. 
 
You asked the Plan to pay for procedure code 88341. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88341 is 13. The MAI value for this code is 3. You billed 23 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for the remaining 10 units of procedure code 88341 billed for date of service May 19, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that this ride was only across 
the street and that a copay should not apply. The Plan denied your request. The Plan says you were charged this 
cost sharing 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 $150 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $150 for these 
services. 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 services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a specialist office visit provided on May 
10, 2022. 
 
You asked the Plan to reduce the copayment for a specialist office visit. You say that you were told the 
provider was in-network 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 $55 
copayment for out-of-network specialist visit. 
 
You have been asked to pay a $55 copayment for a specialist office visit. This item/service falls within the out-
of-network specialist visit 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 
office visit provided on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on July 06, 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 $45 
copayment per visit for a specialist office visit. Covered services include consultation, diagnosis, and treatment 
by a specialist. The provider billed in the amount of $150 and the allowed amount is $39.76. This is less than 
the copayment amount. Therefore, results in the total cost sharing amount of $39.76. 
 
You have been asked to pay a $39.76 copayment, which is less than the 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 06, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for vertical bite-wing radiographs (D0277) provided on June 13, 2022. 
 
You asked the Plan to pay for vertical bite-wing radiographs (D0277). You say that your coverage allows for 
payment of $50 for bite-wing x-rays. The Plan denied your request. The Plan says that this procedure is not a 
benefit under the dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers one set (up to 
four films) of bite-wing radiographs (D0277) every 12 months. 
 
We looked at this file and the Plan rules. The Plan contract says that they cover one set (up to four films) of 
bite-wing x-rays every 12 months. Please note, the Plan contract does not state that specific type of bite-wing 
x-rays are excluded. The enrollee is only bound to the Plans contract. Based on this information, we decided 
that the Plan's rules for coverage of vertical bitewing radiographs (D0277) have been met. Therefore, we 
decided that the Plan has to pay for vertical bite-wing radiographs (D0277) provided on June 13, 2022.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the shoulder injection services provided on March 16, 2022. 
 
You asked the Plan to pay for the services provided. You say that the records support medical necessity. The 
Plan denied your request. The Plan says that the records do not support the billing a second time. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file shows that the enrollee received injection services of the 
right shoulder. We find that the file does not include sufficient evidence to support that the claim at issue is a 
duplicate. The Plan states that the services were previously billed, but this claim was not provided. The Plan 
has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Therefore, we decided that the Plan has to pay for the shoulder injection services provided 
on March 16, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided on April 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a chiropractic visit. You say that you disagree with the denial of chiropractic 
treatment. The Plan denied your request. The Plan says there was no authorization submitted for out-of-
network chiropractic care. 
 
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 a chiropractic visit provided on April 26, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 22214) provided to the 
enrollee on June 6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says procedure code 22214 is not supported the medical records submitted. 
 
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 22214 is "Osteotomy of spine, posterior or posterolateral 
approach, 1 vertebral segment; lumbar." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical documentation did 
not include documentation of an osteotomy of the lumbar spine, using a posterior or posterolateral approach, 
for 1 vertebral segment. The other procedure performed on the L5-S1 would be cumulative of this procedure 
and does not warrant the procedure code.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure code 22214) provided to the enrollee on June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (codes 88368, 88377, G0452) provided on 
March 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that this was an emergent situation, and the lab tests 
were medically necessary. The Plan denied your request. The Plan says the requested services are not covered 
when received by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory testing (codes 88368, 88377, G0452) 
provided on March 21, 2022, 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 limited oral evaluation (D0140), cone beam imaging 
(D0364), a periapical x-ray (D0220), endodontic therapy (D3310), and a resin-based composite filling (D2330) 
provided on June 15, 2022. 
 You asked the Plan to pay for the dental services. You say that the office was told that you had ample coverage 
for the root canal procedure. The Plan denied your request. The Plan says your annual dental benefit maximum 
has 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 this benefit includes 
coverage up to $1,000 for preventive and comprehensive dental services. The contract also says that you are 
responsible for any amount over your coverage benefit limit. 
 
The record shows your annual dental benefit maximum has been met. Therefore, you are responsible for any 
amount above the benefit coverage limit. You have been asked to pay $1,365 for the dental services received 
on June 15, 2022. These items/services fall within the dental 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 pay for a limited oral evaluation (D0140), cone beam imaging (D0364), a periapical x-ray 
(D0220), endodontic therapy (D3310), and a resin-based composite filling (D2330) provided on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive audiometry evaluation 
provided on May 09, 2022. 
 
You asked the Plan to waive the copayment for a comprehensive audiometry evaluation. You say that you were 
told that you would not have a copayment for a hearing test. 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 hearing services. 
 
You have been asked to pay a $10 copayment for a comprehensive audiometry evaluation. This item/service 
falls within the hearing 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 a 
comprehensive audiometry evaluation provided on May 09, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy, a sclerosant injection, and 
a non-compound foam sclerosant injection to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the vascular services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says the requested services are not covered when received by an out-of-
network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
endovenous ablation therapy, a sclerosant injection, and a non-compound foam sclerosant injection to be 
provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac rehab to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve cardiac rehab. You say that you already made an appointment but was 
denied after 2-3 months of waiting. The Plan denied your request. The Plan says The enrollee must receive 
their care from a network provider (for more information about this, see Section 2 in this chapter). In most 
cases, care the enrollee receives from an out-of-network provider (a provider who is not part of our plans 
network) will not be 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 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 
cardiac rehab 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 pre-approve an overdenture (D5865). 
 
You asked the Plan to pre-approve an overdenture. You say that the service is necessary. The Plan denied your 
request. The Plan says the requested 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 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 an 
overdenture (D5865).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an MRI (70551) provided on June 14, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the MRI. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the services denied correctly as they were non-emergent 
and 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 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 MRI (70551) provided on June 14, 2022 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for delivery of a bridge - tooth #6-11 provided on May 20, 2022. 
 
You asked the Plan to pay for dental services. You say that services were previously approved; therefore, you 
are requesting a reconsideration. The Plan denied your request. The Plan says this service is not covered under 
your 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 delivery of a bridge - 
tooth #6-11 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for delivery of a bridge - tooth #6-11 provided on May 20, 2022.