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

 
We decided that the Plan does not have to pay for the filling (D2393) provided on May 12, 2021. 
 
You asked the Plan to pay for the dental service. You say that you want this to be covered. The Plan denied 
your request. The Plan says the filling is not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the filling (D2393) provided on 
May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a onabotulinumtoxina injection provided 
on November 11, 2021. 
 
You asked the Plan to waive the coinsurance for a onabotulinumtoxina injection. You say that the service was 
authorized by the Plan. You also say you were not informed that you would be responsible for partial payment. 
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 20% 
coinsurance for in-network Part B drugs.  
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
$121.60, which is 20% of the allowed amount for a onabotulinumtoxina injection ($608 allowed amount x 20% 
coinsurance = $121.60). A onabotulinumtoxina injection falls within the Medicare Part B Prescription Drugs 
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 a onabotulinumtoxina injection 
provided on November 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on December 8, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you were told that the ultrasound 
would be covered with no copayment. The Plan denied your request. The Plan says when the enrollee called, 
they only requested benefits about a mammogram and not an ultrasound. There was no copayment for the 
yearly mammogram and the proper copayment was applied to the ultrasound. 
 
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 $60 
copayment for Medicare-covered x-ray and ultrasounds.  
 
  You have been asked to pay a $60 copayment for the ultrasound. The ultrasound falls within the Outpatient 
diagnostic tests and therapeutic 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 
copayment for an ultrasound provided on December 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on January 3, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you do not understand why the Plan 
is not contributing to the cost. The Plan denied your request. The Plan says the proper coinsurance was applied. 
 
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% 
coinsurance for Medicare Part B prescription drugs. The total amount allowed was $2,696.17 and the 
coinsurance was $539.08 which is less than a 20% coinsurance amount of $539.23 ($2,696.17 total amount x 
20% coinsurance). 
 
  You have been asked to pay a $539.08 coinsurance for an injection. The injection falls within the Medicare 
Part B prescription drugs 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 an 
injection provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and two additional 
intraoral periapical x-rays (D0230 x2) provided on September 21, 2021. 
 
You asked the Plan to pay for the intraoral periapical x-rays. You say that you believe that the bill you owe is 
incorrect. The Plan denied your request. The Plan says these services are not covered expenses under your 
dental plan. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits 
and provider eligibility. 
 
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 pay for the first 
intraoral periapical x-ray (D0220) and two additional intraoral periapical x-rays (D0230 x2) provided on 
September 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay provided by a 
network facility from September 22, 2021, to September28, 2021. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital stay. You say that you should not be 
responsible for the inpatient hospital stay because you should not have been discharged from the hospital from 
your original surgery. The Plan denied your request. The Plan says you have been asked to pay 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 $400 
copayment for each in-network Medicare-covered hospital stay until discharge.  
 
You have been asked to pay a $400 copayment for the inpatient hospital stay. The inpatient hospital stay 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 coinsurance for 
the inpatient hospital stay provided by a network facility from September 22, 2021, to September28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two periodontal scalings and root planings (D4342 x2) 
provided on December 9, 2021. 
 
You asked the Plan to pay for the scalings and planings. You say that you would like payment for these 
services to be reconsidered. The Plan denied your request. The Plan says this service is not a covered expense 
under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to 
verify 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 pay for the two 
periodontal scalings and root planings (D4342 x2) provided on December 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
October 30, 2021, to October 31, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says a severe medical problem warranting inpatient admission was not 
established. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights.  
 In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not 
cross two midnights or more.  
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record  does not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee from October 30, 2021, to 
October 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 29, 30 and 31, and a 
crown (D2751) for tooth # 31. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says core build up is not a covered service. The Plan says that the frequency 
limit for crowns has been reached with the approval of crowns for teeth # 29 and 30. 
 
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 core build up are not 
among those covered under this benefit. Additionally, the frequency limit for crowns has been reached with the 
approval for crowns on teeth # 29 and 30. Therefore, we decided that the Plan does not have to pre-approve 
core build up (D2950) for teeth # 29, 30 and 31, and a crown (D2751) for tooth # 31.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 4, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like payment for the services that were 
rendered to the enrollee. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 office visit provided on October 4, 2021, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
28, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service December 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the debridement service and the office visit 
provided by a network provider on November 30, 2021. 
 
 
 You asked the Plan to waive the cost share for the debridement service and the office visit. You say that you 
thought the $50 copayment would cover the wax removal. The Plan denied your request. The Plan says you 
have been asked to pay 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 there is $1,250 deductible which applies to the debridement service and a $50 
copayment for each in-person in-network specialist visit.  
 
The debridement service you asked the Plan to waive the cost share for falls within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
The record shows the allowed amount of the debridement service was $77.55, which was applied to the 
deductible. 
 
You have also been asked to pay a $50 copayment for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctors office visits benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is $1,250 deductible that applies towards the 
debridement service and a $50 copayment which applies to each in-person in-network specialist visit.  
 
This cost sharing is a contractual obligation that had not been met at the time the debridement service and the 
office visit was received on November 30, 2021. Therefore, we decided that the Plan does not have to waive 
the cost share for the debridement service and the office visit provided by a network provider on November 30, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0480, 83789 and 80307) provided 
on October 7, 2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not billed with the correct 
POS code. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the drug testing services (G0480, 83789 and 80307) provided on October 
7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular genetic testing services (81479) provided on 
October 4, 2021. 
 
You asked the Plan to pay for cardiovascular genetic testing services. You say that this should be reprocessed 
and approved for payment. The Plan denied your request. The Plan says the billed code is not to be used for 
cardiovascular testing. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing cardiovascular services are subject to 
the criteria listed in the Medicare rules section. 
 
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 pay for cardiovascular genetic testing services. Our 
reviewer says that this testing was not medically reasonable and necessary. Our physician reviewer found at 
issue is whether the requested genetic testing was medically appropriate and necessary. The test is described as 
a genetic based cardiovascular risk factor screening test in which multiple genes are assessed using genomic 
DNA extracted from patient sampling. It assesses the presence of pathogenic or likely pathogenic variants in 
genes known to be associated with increased cardiac risk. It is not a diagnostic test. There is no evidence to 
support its role in this patient clinical management. In summary, the requested testing is not considered 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiovascular genetic testing services have not been met. Therefore, we 
decided that the Plan does not have to pay for cardiovascular genetic testing services (81479) provided on 
October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a clinical crown lengthening (D4249) to be provided by 
a participating provider. 
 
You asked the Plan to pre-approve a clinical crown lengthening. You say that you would like the Plan to pre-
approve these services. The Plan denied your request. The Plan says the requested dental work 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 a 
clinical crown lengthening (D4249) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incomplete root canal (D3332) provided on January 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot afford to pay this extra cost. The 
Plan denied your request. The Plan says incomplete root canal 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 incomplete root canal is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incomplete 
root canal (D3332) provided on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the life vest provided by a network 
provider from October 27, 2021, to November 27, 2021. 
 
You asked the Plan to waive the coinsurance for the life vest. You say that you were never informed there 
would be a charge. You say you would never agree to use the vest if you had known what your charge would 
be. The Plan denied your request. The Plan says you have been asked to pay 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 20% 
coinsurance for in-network Medicare-covered equipment and supplies.  
 
 You have been asked to pay $586.29 which is 20% of the allowed amount for the life vest on each date of 
service. The allowed amount is $2,931.45. ($2,931.45 x 20% = $586.29). The life vest falls within the Durable 
medical equipment (DME) and related 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 the life vest provided by a network provider from October 27, 2021, to November 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250 x 2), and interim 
partial denture (D5821) provided on October 28, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were given a temporary denture. You say 
that you are now being told that you have to wait 6 months for your permanent denture. You also say that you 
keep receiving bills. The Plan denied your request. The Plan says there is a 50% coinsurance for extractions. 
The Plan also says the interim partial denture 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 and removal of residual tooth roots is 
listed as covered, there is a 50% coinsurance that applies. This is a contractual obligation you agreed to when 
you enrolled in the Plan's dental coverage. Additionally, the interim partial denture is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the removal of residual tooth 
roots (D7250 x 2), and interim partial denture (D5821) provided on October 28, 2021.