Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network laboratory tests and an 
out-of-network office visit provided on July 12, 2022. 
 
You asked the Plan to waive the coinsurance for out-of-network laboratory tests and an out-of-network office 
visit. You say that you disagree with the coinsurance. 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 40% 
coinsurance for out-of-network outpatient diagnostic tests/Medicare-covered laboratory tests and a 40% 
coinsurance for out-of-network physician/practitioner services.  You have been asked to pay a 40% coinsurance for out-of-network laboratory tests and a 40% coinsurance for 
an out-of-network office visit. The total allowed amount for the lab test $561.48. You are being asked to pay 
$224.60 ($561.48 x 40% = 224.60). The total allowed amount for the office visit is $204.87. You are being 
asked to pay $81.95 ($204.87 x 40% =$81.95). The total amount you are being asked to pay for all the services 
is $306.55 ($224.60 + $81.95 = $306.55). This item/service falls within the out-of-network outpatient 
diagnostic tests/Medicare-covered laboratory tests and out-of-network physician/practitioner 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 coinsurance for out-of-network laboratory tests and an out-of-
network office visit provided on July 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aide services provided on May 8, 2021. 
 
You asked the Plan to pay for the aide services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services are not medically necessary. 
 
  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in 
this appeal. Therefore, we decided that the Plan does not have to pay for the aide services provided on May 8, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on September 
01, 2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you are not sure why the visit 
was not covered. 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 $55 
copayment for urgently needed services. 
 
You have been asked to pay a $55 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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 urgent 
care visit provided on September 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on August 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep sedation/general anesthesia  first 15 minutes (D9222), 
deep sedation  each subsequent 15 minute increment (D9223), therapeutic parenteral drug, single 
administration (D9610), and  incisional biopsy of oral tissue-soft (D7286) provided on June 13, 2022. 
 
You asked the Plan to pay for the deep sedation/general anesthesia  first 15 minutes (D9222), deep sedation  
each subsequent 15 minute increment (D9223), therapeutic parenteral drug, single administration (D9610), and  
incisional biopsy of oral tissue-soft (D7286) provided on June 13, 2022. You say that the claim was sent to the 
dental department but should have been sent to medical. 
 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 deep 
sedation/general anesthesia  first 15 minutes (D9222), deep sedation  each subsequent 15 minute increment 
(D9223), therapeutic parenteral drug, single administration (D9610), and  incisional biopsy of oral tissue-soft 
(D7286) provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4261) provided on September 27, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental procedure was medically necessary, 
and it should be covered. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the osseous surgery is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for osseous 
surgery (D4261) provided on September 27, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on August 29, 2022. 
 
You asked the Plan to pay for physical therapy services. You say that you are requesting a review of medical 
records and a reconsideration of the denied payment. 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 physical therapy 
services provided on August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a presbyopia correcting function of intraocular lens (V2788) 
provided on July 19, 2022. 
 
You asked the Plan to pay for a presbyopia correcting function of intraocular lens (V2788). You say that you 
should be reimbursed for the presbyopia-correcting intraocular lenses in the amount of $2,500, because that 
would have been the reimbursement if you had had the covered standard lens implant. The Plan denied your 
request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare only covers a standard intraocular lens 
but then enrollee may choose to pay for the non-covered upgrade to a presbyopia-correcting lens.  
 
 
  We looked at the file and Medicare rules. The rules say that Medicare only covers a standard intraocular lens. 
The record shows that you chose the presbyopia correcting function of intraocular lens (V2788). Based on this 
information, we decided that Medicare rules for coverage of a presbyopia correcting function of intraocular 
lens (V2788) have not been met. Therefore, we decided that the Plan does not have to pay for a presbyopia 
correcting function of intraocular lens (V2788) provided on July 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on September 7, 2022, to September 9, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the 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 $215 
copayment for outpatient diagnostic tests/CT.  
 
You have been asked to pay a $215 copayment for a CT scan. This item/service falls within the outpatient 
diagnostic tests/CT 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 computed 
tomography (CT) scan provided on September 7, 2022, to September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (D0364), endodontic 
therapy (D3330), and a consultation (D9310) for tooth #14 provided on August 19, 2022, and August 22, 2022 
 
You asked the Plan to pay for the dental services. You say that you were told by an agent of records that the 
services would be covered. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the cone beam computed tomography, endodontic therapy, and the consultation are 
not covered by the Plan. Also, it was verified that the enrollee never contacted the Plan prior to the dates of 
service. 
 
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 cone 
beam computed tomography (D0364), endodontic therapy (D3330), and a consultation (D9310) for tooth #14 
provided on August 19, 2022, and August 22, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 01, 2022. 
 
You asked the Plan to pay for office visit. You say that you were not aware that you had to get pre-approval to 
see a doctor you have been seeing for such a long time. 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 provided on 
June 01, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 15, 2022, to 
August 13, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 15, 2022, to August 
13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy provided on July 19, 2022. 
 
You asked the Plan to pay for chemotherapy. You say that you are requesting reconsideration. 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 chemotherapy provided 
on July 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5226). 
 
You asked the Plan to pre-approve the dental service. You say that you need a new partial denture because of 
your root canal. 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 the date of service of November 17, 
2021. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5226).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dual-energy X-ray absorptiometry (DXA) bone density 
study provided on April 25, 2022. 
 
You asked the Plan to pay for the dual-energy X-ray absorptiometry (DXA) bone density study. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
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, the CPT Code Manual definition of code 77080 is dual-energy X-ray absorptiometry (DXA), bone 
density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine). 
 
We find that CPT code 77080 is not supported in the medical record. Specifically, this service was billed with 
diagnosis code Z78.0 (asymptomatic menopausal state). This diagnosis is not typically billed for an enrollee 
with a gender of male. A modifier to clarify a special circumstance has not been billed with this code. This 
service is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the 
dual-energy X-ray absorptiometry (DXA) bone density study have not been met. Therefore, we decided that the 
Plan does not have to pay for the dual-energy X-ray absorptiometry (DXA) bone density study provided on 
April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit and debridement provided on August 01, 2022. 
 
You asked the Plan to pay for office visit and debridement. 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 
debridement provided on August 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on 
August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received a D0431 diagnostic test from a 
participating provider and are appealing the denial of this service. The Plan denied your request. The Plan says 
your benefit for the requested item or service $1,000 dollar limit as met. 
 
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 by other services on August 23, 2022 due to 
dates of service August 25, 2022 and August 30, 2022, processing before the claim for the services at issue. 
Therefore, we decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) 
provided on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Noom weight loss subscription purchased on October 11, 
2022. 
 
You asked the Plan to pay for Noom weight loss subscription. You say that you would like your insurance to 
cover the subscription for Noom because it is a health and wellness program. The Plan denied your request. 
The Plan says this program is not covered under your dental benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that Nutritional/dietary counseling must be provided 
by practitioners who are licensed or certified, as applicable, in the state in which they practice and are 
furnishing services within the scope of practice defined by their licensing or certifying state. Meal plans 
included as part of weight loss programs, lab work and allergy tests are excluded from this benefit.  
 
  We looked at the file and Medicare rules. The Plans rules for coverage of weight loss programs have not been 
met because you are requesting authorization for payment of a web/app-based weight loss subscription. The 
Pick your perks program only covers nutritional/dietary when provided by practitioners who are license or 
certified.  Therefore, we decided that the Plan does not have to pay for Noom weight loss subscription 
purchased on October 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on 
September 08, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered. 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for ambulance transport. This item/service falls 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. You have been asked to pay $400 ($200 per trip) copayment for the ambulance transports. 
Therefore, we decided that the Plan does not have to waive the copayment for ambulance transport provided on 
September 08, 2022.