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

 
We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy performed 
on January 21, 2022. 
 
You asked the Plan to waive the copayment for the aspiration biopsy. You say that you were not aware that the 
procedure was considered outpatient instead of radiology. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each surgery or service at an outpatient hospital facility.  
 
You have been asked to pay a $250 copayment for the aspiration biopsy. The aspiration biopsy is considered a 
surgical procedure and falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers 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 fine needle aspiration biopsy performed on January 21, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided on January 7, 2021. 
 
You asked the Plan to pay for therapy services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services were billed past the timely filling limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for therapy services was not filed until March 21, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for occupational therapy services provided on January 7, 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 July 
16, 2021, to July 23, 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 has reported inpatient hospital services with the incorrect DRG.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 the 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found that the review has determined A41.89 - other specified sepsis - is not supported 
in the documentation. The records do not support the use of DRG 871 in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from July 16, 2021, to July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit (99334) provided on February 16, 2022 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. 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 a rest home visit (99334) provided on February 
16, 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) provided on April 15, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial of code D0140 - 
limited exam to evaluate a problem, one procedure per plan year, for date of service April 15, 2022. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 12, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for analysis of saliva sample (D0418), collection and preparation 
of saliva sample for laboratory diagnostic testing (D0417) and gingival irrigation-per quadrant (D4921) 
provided on March 30, 2022. 
 
You asked the Plan to pay for analysis of saliva sample (D0418), collection and preparation of saliva sample 
for laboratory diagnostic testing (D0417) and gingival irrigation-per quadrant (D4921). You say that with your 
plan these services should be covered. The Plan denied your request. The Plan says these services are not 
covered under the enrollee's 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for analysis 
of saliva sample (D0418), collection and preparation of saliva sample for laboratory diagnostic testing (D0417) 
and gingival irrigation-per quadrant (D4921) provided on March 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a prime care appointment with multiple injections 
provided on April 8, 2022. 
 
You asked the Plan to waive the cost for a prime care appointment with multiple injections. You say that you 
wanted to be sure this is a real charge. The Plan denied your request. The Plan says the cost charged was 
correct. 
 
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 $25 
copayment for Primary Care Provider (PCP) office visit and 20% coinsurance Medicare Part B prescription 
drugs.  
 
You have been asked to pay a total copayment of $28.77 (injections: $1.61 x 20% = 0.32 
$17.25 x 20% = $3.45) and ($25 PCP copayment + $3.45 + $0.32 = $28.77). A prime care appointment with 
multiple injections falls within the Primary Care Provider (PCP) Office visit and 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 cost for a prime care appointment with multiple injections provided on 
April 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D2394, D0220, D0140, D1999, and D2392) 
from March 21, 2022, to April 15, 2022. 
 
You asked the Plan to pay for dental services (D2394, D0220, D0140, D1999, and D2392). You say that you 
would like to request reconsideration of the denied claim because the plan failed to give you accurate 
information. The Plan denied your request. The Plan says dental services provided for date of services 
3/21/2022 through 4/15/2022 are being partially overturned. 
 
Claim 202203226242588 for date of service 03/21/2022 was reprocessed on 06/09/2022. The (D2394) resin-
based composite - four or more surfaces posterior, (D0140) Limited oral evaluation - problem focused & 
(D0220) preapical first radiographic image services have been paid. The plan paid $744.00, and the member has a responsibility of $0.00.  Claim 202204016273438 for date of service 03/30/2022 was reprocessed on 06/09/2022. The (D0140) limited oral evaluation - problem focused & (D0220) periapical first radiographic image denied 7NG because benefits for this service have been satisfied and the frequency limitation has been exceeded. The (D1999) preventive procedure denied because the issue is not a covered expense under the dental plan. 
 
Claim 202204086697857 for date of service 04/06/2022 was reprocessed on 06/09/2022. The (D2392) resin-
based composite - two surfaces, posterior services have been paid. The plan paid $379.00, and the member has 
a responsibility of $137.00. The Dental code (D3120) Pulp Cap denied because these services are not a covered 
expense under your dental plan.  
 
Claim 202204196797803 for date of service 04/15/2022 was reprocessed on 06/09/2022. The (D2392) resin-
based composite - two surfaces, posterior is paid for. The plan paid $347.00, and the member has $0.00 copay. 
The (D2392) resin-based composite - two surfaces, posterior denied because the Dental Maximum has been 
met and no further benefits are available. 
 
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 pulp 
cap (D3120), preventive procedure (D1999), and the periapical first radiographic image (D0220, on 3/30/2022) 
from March 21, 2022, to April 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for glucose monitor, and testing strips provided on November 
27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for glucose monitor and testing strips. You say that you did not know you needed a 
pre-authorization. The Plan denied your request. The Plan says the service can be provided by an in-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 glucose monitor, and testing strips provided on 
November 27, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replacement of missing or broken teeth on a complete 
denture (D5520) provided on March 9, 2022. 
 
You asked the Plan to pay for the replacement of missing or broken teeth. You say that when you first applied 
for this plan, you were told dentures and repairs would be covered. The Plan denied your request. The Plan 
says this service is not covered. 
 
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 
replacement of missing or broken teeth on a complete denture (D5520) provided on March 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit  provided on September 30, 
2021, by an out-of-network provider. 
 
You asked the Plan to pay for the rest home visit. You say that the provider has no option to determine which 
patient he wants to perform services on. The Plan denied your request. The Plan says the services were billed 
by, rendered by, and referred by non-participating providers with the plan. The Plan also says that these 
services were not urgent or emergent, nor were they approved in advance. 
 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 domiciliary or rest home visit  provided on 
September 30, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a lab visit, and a specialist visit provided 
on March 1, 2022. 
 
You asked the Plan to waive the copayments for a lab visit and a specialist visit. You say that the provider 
refused to see you and that you did not have lab work done. The Plan denied your request. The Plan says the 
copayments applied were correct. According to medical records, this will be upheld. 
 
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 $30 
copayment for a specialist visit for Physician/Practitioner services, including doctors office visits and a $10 
copayment for laboratory tests ($30 + $10 = $40).  
 
You have been asked to pay a $40 copayment for a specialist visit and lab work which falls into the 
Physician/Practitioner Services, Including Doctors Office Visits and Laboratory Tests 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 copayments for a lab visit, and a specialist visit provided on 
March 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
February 2, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were transferred from 
the hospital without being given the option of having your family transport you. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment per one-way trip for ambulance services.  
 
You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the 
Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
services provided on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service provided 
on January 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that the service was 
medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
telephone evaluation and management service. We found no exception that would require the Plan to pay for 
the telephone evaluation and management service. The records provided for review do not show that the 
service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the 
telephone evaluation and management service provided on January 20, 2022, by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, nail debridement, and excision of nail provided 
on April 19, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a home visit, nail debridement, and excision of nail. You say that it was 
medically necessary to treat the enrollee and you would like the claim reprocessed for payment. The Plan 
denied your request. The Plan says the rendering provider is an OON 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 a home visit, nail debridement, and excision of 
nail provided on April 19, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on March 31, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 testing provided on March 31, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth visit provided on February 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for telehealth visit. You say that you were not aware you needed to get prior 
authorization. The Plan denied your request. The Plan says the service can be provided by an in-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 telehealth visit provided on February 7, 2022, by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided on February 28, 2022. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the skilled 
nursing services are not approved because the beneficiary enrolled in hospice care on February 28, 2022. 
 
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 the skilled nursing services provided on February 28, 2022.