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

 
We decided that the Plan does not have to pre-approve the extractions, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided February 5, 2021, and February 22, 2021, and repair resin denture 
base (D5610) provided March 31, 2021. 
 
You asked the Plan to pre-approve the tooth extractions and denture repair. You say that you would like the 
services covered. The Plan denied your request. The Plan says the services were provided out-of-network and 
therefore 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. The Plan covers the tooth 
extractions and denture repair when rendered by a provider in the Plan?s dental vendor network.  
 We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the tooth extractions and denture repair have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) 
provided February 5, 2021, and February 22, 2021, and repair resin denture base (D5610) provided March 31, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the crown (D2740) provided on May 20, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that this service should be covered. The 
Plan denied your request. The Plan says the crown 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 crown is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the crown (D2740) 
provided on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine vision services (92015, 92451, V2020, V2203) 
provided on January 12, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the routine vision services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by 
an OON provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are rendered by an in-network provider. 
 
We looked at the file and the Plan's rules. In this case, prior authorization was not obtained for these non-
emergent services rendered by an OON provider as required by the Plan?s contractual rules. Based on this 
information, we decided that the Plan's rules for coverage of the routine vision services have not been met. 
Therefore, we decided that the Plan does not have to pay for the routine vision services (92015, 92451, V2020, 
V2203) provided on January 12, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the audiology testing you had at an 
outpatient hospital facility on March 23, 2021. 
 
You asked the Plan to waive the copayment for the audiology testing. You say that you called the Plan and 
were advised that this provider was the closest one to you that took your insurance.  You later found out that 
this provider is not a covered provider with your hearing benefit.  You stated that the copayment should be 
waived because you were given incorrect information. The Plan denied your request. The Plan says you were 
charged this copayment 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 $95 copayment for diagnostic tests at an outpatient hospital facility.  
 
You have been asked to pay a $95 copayment for the audiology testing. Your contract says that in order to 
access the routine hearing exam benefit at $0 copayment, you must call TruHearing to schedule your 
appointment.  Records show that you called the Plan, not TruHearing, to request a provider name to go to.  As a 
result, you were given information to receive services at an outpatient hospital facility.  Because you received 
the audiology testing at an outpatient hospital facility, 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 $0 copayment for hearing tests only applies if you schedule your exam by 
calling TruHearing.  Therefore, we decided that the Plan does not have to waive the copayment for the 
audiology testing you had at an outpatient hospital facility on March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on June 3, 
2021. 
 
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 the provider is not recognized as a physician or non-physician practitioner. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
 
 
 
 
 In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. The provider is considered a Registered Nurse First Assistant. Medicare only makes payment for 
surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the 
Plan does not have to pay for surgical assistant services provided to the enrollee on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic X-ray (D0330) and a complete set of dentures 
(D5110, D5120) provided on March 30, 2021. 
 
You asked the Plan to pay for a panoramic X-ray and a complete set of dentures. You say that the requested 
services were a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
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. The Plan covers either a 
panoramic X-ray or full mouth X-rays at the rate of one procedure code per calendar year and covers complete 
dentures every five years. 
 We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a panoramic X-ray and a complete set of dentures have not been met. Specifically, the Plan has 
documented that coverage has been provided for full mouth X-rays earlier than the date of service and within 
the same calendar year. The Plan has also documented that coverage has been provided for a complete set of 
dentures within the past five years prior to the date of service. Therefore, we decided that the Plan does not 
have to pay for a panoramic X-ray (D0330) and a complete set of dentures (D5110, D5120) provided on March 
30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) and chiropractic 
manipulation treatment (98943) provided June 14, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that you would like to be reimbursed the $25. 
The $45 was charged before you and the provider talked. You had to pay that up front. The Plan denied your 
request. The Plan says these services are not covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99213) and chiropractic manipulation treatment 
(98943) provided June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the educational supplies represented by code 99071 provided 
on November 25, 2020. 
 You asked the Plan to pay for code 99071. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Code 99071 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the educational supplies represented by code 99071 provided on 
November 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic intercept provided to the enrollee on October 14,
2020.
You asked the Plan to pay for this transport and service. You say that these services should be covered by the
Plan. The Plan denied your request. The Plan says paramedical intercept services are not covered by Medicare.

The QIC overturned the Plans denial. The Plan requested a reopen and stated that wedid not apply the
correct Medicare criteria.
The Plan is correct in this case. The rules say that Medicare pays for advanced life support (ALS), in
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT Paramedic
only in certain circumstances. Medicare allows ALS paramedic intercept services only when the
services are furnished in a rural area as defined above. The paramedic intercept services at issue in this appeal
were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we
decided that the Plan does not have to pay for paramedic intercept provided to the enrollee on October 14,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study (93971) rendered by the OON provider 
on April 21, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the extremity study (93971) rendered by the out-of-network (OON) provider on  
April 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the stress test, the Tetrofosmin 
radiopharmaceutical supply, and the Regadenoson injection you received on March 17, 2021, and the 
cardiology visit and electrocardiogram (ECG) you received on March 24, 2021. 
 
You asked the Plan to waive the cost sharing for the stress test, the Tetrofosmin radiopharmaceutical supply, 
the Regadenoson injection, the cardiology visit, and the ECG. You say that the office would not accept a 
copayment at the time of the visit.  The original statement said this service was not approved.  You feel as 
though the copayment should not be included in the amount billed. The Plan denied your request. The Plan 
says you were charged this cost sharing correctly.  The Plan says that for the ECG, the allowed amount for this 
test ($11.98) is less than your copayment responsibility, so you are responsible for the full allowed amount for 
this service.  
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 $20 
copayment for non-radiological diagnostic services, 20% coinsurance for medical supplies, 20% coinsurance 
for Medicare Part B drugs, and a $35 copayment for office visits with a specialist.  
 
You have been asked to pay a $20 copayment for the stress test and the ECG.  You have been asked to pay 
20% coinsurance for the Tetrofosmin radiopharmaceutical supply and the Regadenoson injection.  You have 
also been asked to pay a $35 copayment for the cardiology visit. The stress test and the ECG fall within the 
non-radiological diagnostic services benefit category.  The Tetrofosmin is considered a medical supply.  The 
Regadenoson injection is a Medicare Part B drug.  Finally, a cardiologist is considered a specialist, so the 
specialist office visit applies. This means that you have been asked to pay the correct amounts 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 sharing for the stress test, the 
Tetrofosmin radiopharmaceutical supply, and the Regadenoson injection you received on March 17, 2021, and 
the cardiology visit and electrocardiogram (ECG) you received on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for services you received at a cardiologist's 
office on October 27, 2020. 
 
You asked the Plan to waive the copayment for the cardiology services. You did not provide an argument in 
your appeal request. The Plan denied your request. The Plan says you were charged this copayment 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 $35 
copayment for services with a specialist.  
 
You have been asked to pay a $35 copayment for the cardiology services. The cardiology services fall within 
the services with a specialist 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 services you 
received at a cardiologist's office on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the immediate partial upper denture (D5221), 
extraction (D7210), and bone replacement graft (D7953) provided from June 7, 2021, to July 6, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that you did not authorize your plan to 
change. You also say that you are requesting reimbursement based on the original coverage of your plan. The 
Plan denied your request. The Plan says there is a 50% coinsurance for extractions received in network. The 
Plan also says the immediate partial upper denture and bone replacement graft are not listed as covered 
services. 
 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 immediate partial upper denture 
and bone replacement graft are not among those covered under this benefit. While extractions are a covered 
service, there is a 50% coinsurance when received in network. Therefore, we decided that the Plan does not 
have to reimburse you for the immediate partial upper denture (D5221), extraction (D7210), and bone 
replacement graft (D7953) provided from June 7, 2021, to July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), cleaning (D1110), and bitewing x-
rays (D0274) provided on August 11, 2021. 
 
You asked the Plan to pay for the dental services. You say that you have been going to this dentist for many 
years. You also say that there are no other dentists close to you that participate. The Plan denied your request. 
The Plan says the provider in this case is out of network. The Plan also says that dental services you receive out 
of network 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 services received out of network 
are not among those covered under this benefit. Additionally, the record shows there are in network dentists 
available within 10 miles of your home. Therefore, we decided that the Plan does not have to pay for the oral 
exam (D0120), cleaning (D1110), and bitewing x-rays (D0274) provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 18, 2020. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on November 18, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services received from May 29, 2021, to May 30, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be reprocessed for payment. The Plan 
denied your request. The Plan says these items are not covered. 
 
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. Additionally, the denied services coded with A9270 are not covered. The definition of this 
code is 'Non-covered item or service.' Therefore, we decided that the Plan does not have to pay for the 
services received from May 29, 2021, to May 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on April 29, 2021. 
 
You asked the Plan to pay for physical therapy services. You say that it was impossible for the office to obtain 
authorization due to the patient misleading the office with the incorrect insurance information. The Plan denied 
your request. The Plan says members must receive care from an in-network provider. In most cases, care 
members receive from an out-of-network provider will not be covered. If the member needs medical care that 
Medicare requires our Plan to cover and the providers in our network cannot provide this care, the member can 
get this care from an out-of-network provider. Authorization should be obtained from the Plan prior to seeking 
care. It is the provider?s responsibility to check member eligibility prior to rendering services. 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 physical therapy services provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and 
comprehensive oral evaluation - new or established patient (D0150) provided August 5, 2021. 
 
You asked the Plan to pay for the panoramic x-ray and comprehensive oral exam. You say that you were not 
aware of the coverage limit and the services were medically necessary. The Plan denied your request. The Plan 
says you have exceeded frequency limits for the services at issue. 
 
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. The Plan covers the panoramic 
x-ray and comprehensive oral exam once every three plan years. 
 
 
 We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam and panoramic x-ray were previously covered on September 16, 2020. Based on this information, we 
decided that the Plan's frequency limit for coverage of the panoramic x-ray and comprehensive oral exam have 
been exceeded. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image 
(D0330) and comprehensive oral evaluation - new or established patient (D0150) provided August 5, 2021.