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

 
We decided that the Plan does not have to pay for bitewings (D0274), prophylaxis (D1110), a periodic oral 
evaluation (D0120), and intraoral imaging (D0220), provided by an out-of-network provider on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have had the same dentist for 9 years. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for bitewings (D0274), prophylaxis (D1110), a periodic oral evaluation (D0120), and intraoral imaging 
(D0220), provided by an out-of-network provider on April 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services billed by a Certified Surgical First 
Assistant (CSFA). 
 
You asked the Plan to pay for the CSFA services. You say that the provider's surgical assistance was needed 
and utilized in this case. The Plan denied your request. The Plan says an assistant surgeon may not be paid for 
this procedure. 
 
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. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Further, nowhere in the medical record is the use of a surgical assistant documented.  The 
medical records are silent on the use of a surgical assistant for this procedure, so these services cannot be verified. Therefore, we decided that the Plan does not have to pay for surgical assistant services billed by a 
Certified Surgical First Assistant (CSFA).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 14, 2022. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code 
cannot be separately reimbursed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 We looked at the file and Medicare rules. The testing described by billed code 83789 is considered specimen 
validity testing which is not separately payable. 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 laboratory services provided on March 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a capsule endoscopy. 
 
You asked the Plan to pre-approve a capsule endoscopy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a capsule endoscopy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the presence of obstruction is considered a contraindication to the requested 
procedure. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a capsule endoscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a capsule endoscopy.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nourianz. 
 
You asked the Plan to pre-approve Nourianz. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B benefit. 
 
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 pre-approve Nourianz.  
 
 
 Benefits for Nourianz 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided by an 
out-of-network provider on May 26, 2022, to May 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these 
services. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodontal scaling and root planing (D4341) provided by an out-of-network provider on May 26, 
2022, to May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic laboratory testing provided on April 5, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for testing. You say that this testing was medically necessary. The Plan denied your 
request. The Plan says there is no prior authorization for these 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 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 genetic laboratory testing provided on April 5, 
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 an extraction (D7210) and a limited oral evaluation (D0140) 
provided by an opt-out provider on November 9, 2021. 
 
You asked the Plan to pay for an extraction and a limited oral evaluation. You say that you would like the Plan 
to pay for this. The Plan denied your request. The Plan says the rendering dentist has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an 
extraction (D7210) and a limited oral evaluation (D0140) provided by an opt-out provider on November 9, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic supplies on January 05, 2022, to 
January 28, 2022. 
 
You asked the Plan to waive the coinsurance for diabetic supplies. 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 35% 
coinsurance for diabetic shoes and inserts at durable medical equipment provider and prosthetics provider. The 
provider billed in the amount of $3,750 and the allowed amount is $263.45. $263.45 x 35% = $92.21. 
Therefore, results in the total cost sharing amount of $92.21. 
 
 
 
 
 You have been asked to pay a 35% coinsurance for diabetic supplies. This item/service falls within the 
Diabetes self-management training, diabetic services and supplies 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 coinsurance for diabetic supplies on January 05, 2022, to January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 
22, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you saw this provider 
one time while in the hospital. 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 $35 
copayment for specialist visits. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
specialist 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 the specialist office visit 
provided on April 22, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
November 08, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you checked in but did 
not go back and see the provider. 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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for an emergency room visit. This item/service falls within the 
emergency 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 an emergency room visit 
provided on November 08, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown on May 24, 2022, to July 24, 
2022. 
 
You asked the Plan to pay for a porcelain/ceramic crown. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the 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 pay for a 
porcelain/ceramic crown on May 24, 2022, to July 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on May 
07, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you feel you were 
admitted and should not have this copayment. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for emergency care. 
 
You have been asked to pay a $100 copayment for an emergency room visit. This item/service falls within the 
emergency 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 an emergency room visit 
provided on May 07, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Continuous positive airway pressure 
(CPAP) device and supplies provided on May 25, 2022. 
 
You asked the Plan to waive the coinsurance for Continuous positive airway pressure (CPAP) device and 
supplies. 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 10% 
coinsurance for durable medical equipment. 
 
You have been asked to pay 10% coinsurance for Continuous positive airway pressure (CPAP) device and 
supplies. This item/service falls within the durable medical equipment 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 coinsurance for Continuous positive airway pressure (CPAP) device and supplies 
provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on April 22, 2022.

You asked the Plan to pay for anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee's Plan excludes coverage for this out-of-network service.

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 anesthesia services provided on April 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on November 4, 2021. 
 
You asked the Plan to pay for the medical services. You say that this claim was filed timely, so it should be 
processed. The Plan denied your request. The Plan says it is not responsible for this bill. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided from February 22, 2022, to March 
3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows the enrollee received the requested dental services from an out-of-network provider. Though 
the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered 
under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not 
have to pay for dental services provided from February 22, 2022, to March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88342 billed for date of service March 9, 
2022. 
 
You asked the Plan to pay for procedure code 88342. You say that the medical records support separate billing 
for this service. The Plan denied your request. The Plan says payment for code 88342 is bundled into payment 
for code 88344. 
 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 88342 
is a column II code to column I code 88344. This claim has not been billed with an appropriate modifier to 
bypass the edit. Please note that you only appended the 59 modifier to code 88323.  You did not append it to 
code 88342. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 88342 billed for date of service March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) and oroantral fistula 
closure (D7260), provided by a participating provider. 
 
You asked the Plan to pre-approve a bone replacement graft and oroantral fistula closure. You say that these 
services are medically necessary. The Plan denied your request. The Plan says the requested dental services are 
not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone replacement graft (D7953) and oroantral fistula closure (D7260), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392) 
provided on May 18, 2022. 
 
You asked the Plan to pay for dental services. You say that if you had been made aware of your only option 
being resin, you would have found a different provider. 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 resin-based composite - 
two surfaces, posterior (D2392) is not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for resin-based composite - two surfaces, posterior (D2392) provided on May 18, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 21, 
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 traditional Medicare pays for these services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 21, 
2022.