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

 
We decided that the Plan does not have to pay for ambulance services provided on September 8, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was not enrolled in hospice on the 
date of service in question and would like the claim to be reprocessed. The Plan denied your request. The Plan 
says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on September 1, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on September 8, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastric emptying imaging study (78264) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a gastric emptying imaging study. You say that you had to go out of state 
for a separation, but thought you would be back by now. You also say that you have to spend more time out of 
state, and need services from an OON provider. The Plan denied your request. The Plan says a non-emergent 
scan was ordered at an out of network facility. The Plan also says there are facilities within 30 miles of your 
home address that are in-network that can provide this scan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a gastric emptying imaging study (78264) to be provided 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 a colonoscopy provided on September 26, 
2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you are disputing the share cost. 
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 $390 
copayment for Outpatient hospital services. 
 
You have been asked to pay a $390 copayment for a colonoscopy. This item/service falls within the Outpatient 
hospital services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a colonoscopy 
provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit and flu vaccine provided on October 26, 2021. 
 
You asked the Plan to pay for office visit and flu vaccine. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit and flu 
vaccine provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core in addition to crown provided 
(D2954) on December 23, 2021. 
 
You asked the Plan to pay for a prefabricated post and core. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the denied 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 pay for a 
prefabricated post and core in addition to crown provided (D2954) on December 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bifocal lenses provided on September 14, 2022. 
 
You asked the Plan to pay for bifocal lenses. You say that the denial fails to state how this determination was 
reached. The Plan denied your request. The Plan says the member has already used this portion of the vision 
care benefit for this period. 
 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 once every year. 
 
We looked at the file and the Plan's rules. The Plan rules say that one pair of eyeglass frames and lenses are 
covered every year. The record shows this benefit was exhausted on August 26, 2022. Based on this 
information, we decided that the Plan's rules for coverage of bifocal lenses have not been met. Therefore, we 
decided that the Plan does not have to pay for bifocal lenses provided on September 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on October 27, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. 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. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the durable medical equipment provided on October 27, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 11, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on  
November 30, 2022. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service November 10, 2022. Specifically, 
the Plan provides coverage of two periodic oral evaluations per year. You previously received these services on 
February 7, 2022 and November 10, 2022, which were paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for these services. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120) provided on November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) for tooth #20 provided on July 26, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service was medically necessary. The 
Plan denied your request. The Plan says your annual dental benefit for the year 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 July 26, 2022. On April 
4, 2022, the Plan paid $1,444 for dental services. On July 26, 2022, the Plan paid $556 for dental services. For 
the year of 2022 the Plan paid a total of $2,000 ($1,444 paid + $556 paid) for dental services. Therefore, we 
decided that the Plan does not have to pay for a crown (D2740) for tooth #20 provided on July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 15, 2022, billed with 
codes 81225. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with single panel code 81479, as required. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on June 15, 2022, billed with codes 81225.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided from April 14, 2022, to April 
15, 2022. 
 
You asked the Plan to pay for the services. 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. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 58150. This code is listed with a status indicator of 
C on Addendum B of the 2022 OPPS/ASC final rule. This means the service has been designated as 
inpatient only, and therefore must be billed as part of an inpatient admission. The services were billed on an 
outpatient claim. Therefore, we decided that the Plan does not have to pay for the surgical services provided 
from April 14, 2022, to April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) rendered by 
the out-of-network (OON) provider from March 14, 2022, through May 18, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as they were 
rendered by an ineligible 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. 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 the chiropractic manipulative treatments (98941) rendered by the out-of-network 
(OON) provider from March 14, 2022, through May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth service provided on December 07, 2021. 
 
You asked the Plan to pay for telehealth service. You say that the records attached support the services 
provided The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for telehealth service 
provided on December 07, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an abdominal magnetic resonance imaging 
(MRI) scan provided on June 20, 2022. 
 
You asked the Plan to waive the copayment for an abdominal magnetic resonance imaging (MRI) scan. You 
say that this service should be covered in full. 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 $275 
copayment for in-network diagnostic radiology services other than computerized tomography (CT) scans. 
 
You have been asked to pay a $275 copayment for an abdominal magnetic resonance imaging (MRI) scan. This 
item/service falls within the in-network diagnostic radiology services other than computerized tomography 
(CT) scans 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 abdominal magnetic 
resonance imaging (MRI) scan provided on June 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-rays provided on October 27, 2022. 
 
You asked the Plan to waive the copayment for x-rays. 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 $75 
copayment for outpatient hospital services. 
 
You have been asked to pay a $75 copayment for x-rays. This item/service falls within the outpatient hospital 
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 x-rays provided on October 
27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a sleep study. You say that you need this sleep study. The Plan denied your 
request. The Plan says the requested services can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a sleep study to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on April 13, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are disputing the share cost. 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 $275 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $275 copayment for CT scan. This item/service 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 CT scan provided on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network lab services provided on August 
12, 2022. 
 
You asked the Plan to waive the copayment for in-network lab services. You say that you would have had this 
done at your primary care office but it was too painful. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for in-network lab services. This item/service 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 in-network lab services provided on August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on July 22, 2022. 
 
You asked the Plan to pay for outpatient hospital services. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for outpatient hospital 
services provided on July 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, of an erupted tooth or exposed root  
(D7140 x 20), the extractions, of an erupted tooth requiring removal of bone and/or sectioning of tooth  
(D7210 x 3), an immediate upper denture (D5130), an immediate lower denture (D5140), and the unspecified 
removable prosthodontic procedures, by report (D5899 x 2) provided on October 26, 2022 
 
You asked the Plan to pay for these dental items/services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says these items/services are 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 items/services provided are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extractions, of an erupted tooth or exposed root (D7140 x 20), the extractions, of an erupted tooth requiring 
removal of bone and/or sectioning of tooth (D7210 x 3), an immediate upper denture (D5130), an immediate 
lower denture (D7140), and the unspecified removable prosthodontic procedures, by report (D5899 x 2) 
provided on October 26, 2022