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

We decided that the Plan does not have to reimburse you for the diagnostic cases (D0470), sales tax (D9985), autogenous connective tissue graft procedure, first tooth (D4273), and autogenous connective tissue graft procedure, each additional tooth (D6283 x 2) provided on March 11, 2021.
You asked the Plan to reimburse you for the dental services. You say that you had a soft tissue graft procedure done. You say that your dental plan denied the claim. You say that you were advised it was a medical claim. You also say that this has been denied under your medical benefit too. The Plan denied your request. The Plan says the services you received are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to reimburse you 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 reimburse you for the diagnostic cases (D0470), sales tax (D9985), autogenous connective tissue graft procedure, first tooth (D4273), and autogenous connective tissue graft procedure, each additional tooth (D6283 x 2) provided on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee. 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is non-covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered 
because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve 
a power seat elevation feature (E2300) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 6, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out-
of-network (OON) provider on October 5, 2021. 
 
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 the services were rendered by an out of 
network provider, without prior authorization. 
 
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 laboratory services (88305, 88312) rendered by the out-of-network (OON) 
provider on October 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
brain provided on October 20, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that the order was not filled out correctly and 
because of it you had to go back for a second MRI. 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 $100 
copayment for advanced imaging for each in-network freestanding radiological facility visit. 
 
 You have been asked to pay a $100 copayment for an MRI. An MRI falls within the Advanced Imaging 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 magnetic resonance imaging (MRI) of the 
brain provided on October 20, 2021.  
 
Your complaint about the incorrect order and having to go back a second time is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on July 13, 
2021. 
 
You asked the Plan to pay for the mandibular partial denture. You say that the sales agent and provider both 
assured you that this procedure would be covered. The Plan denied your request. The Plan says this service is 
not a covered expense under your dental plan. The Plan also says that your call with the Plan was reviewed, 
and you never inquired about any specific dental codes, or specifically code D5214. 
 
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 
mandibular partial denture (D5214) provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 19, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the medical 
records do not support the coding criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   In this case, the CPT Code Manual definition of code G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
the ordering of 15-21 drug classes were ordered due to clinical history, suspicious behaviors, or changes in 
behavioral patterns. Based on this information, we decided that Medicare rules for coverage of the testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on May 12, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 83789 (mass spectrometry) and G0480 (definitive drug 
testing, 1-7 drug classes). Code 83789 is a column II code with a modifier indicator of 1 when billed with 
column I code G0480. Code 83789 was not billed with an appropriate modifier to allow for separate payment. 
The file does not support the use of the -59 modifier as a separate and distinct service. Therefore, we decided 
that the Plan does not have to pay for the mass spectrometry rendered on May 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for ultrasounds provided on July 9, 2021.
You asked the Plan to waive the deductible and copayment for ultrasounds. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 a $500 deductible. Your contract with the Plan also clearly says that after the $500 deductible has been met, enrollee's must pay a $75 copayment for ultrasounds. You received ultrasounds on July 9, 2021. The record shows that you had only paid $180.84 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $319.16. Now that the $500 deductible has been met you are also responsible to pay the remaining allowed amount of $33.15, which is less than the $75 copayment. The total amount you owe is: $352.31.
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time ultrasounds was received on July 9, 2021. Therefore, we decided that the Plan does not have to waive the deductible and copayment for ultrasounds provided on July 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion therapy (99601, S9338 and 99602) to be 
provided to the enrollee.
 
You asked the Plan to pre-approve the therapy. You say that the therapy is medically necessary. The Plan 
denied your request. The Plan says that these services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Specifically, these codes have a status indicator of I according to the Medicare Physician's Fee Schedule. This 
indicates that these codes are not valid for Medicare purposes. Based on this information, we decided that 
Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home infusion therapy (99601, S9338 and 99602) to be provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), 
panoramic x-ray (D0330), extraction (D7210), implant (D6010), and bone graft at time of implant placement 
(D6104) provided on June 22, 2021. 
 
You asked the Plan to pay the in network rate for the evaluation, implant, and bone graft. You say that you 
were referred for these services by your in network dentist. You say that you were told you had to pay on the 
spot. You say that you have acted in good faith but your plan has not. You also say that The Plan denied your 
request. The Plan says the limited oral evaluation, implant, and bone replacement graft are not listed as covered 
services. 
 
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 limited oral evaluation, implant, 
and bone replacement graft are not among those covered under this benefit, regardless of the provider's 
network status. Therefore, we decided that the Plan does not have to pay the in network rate for the limited oral 
evaluation (D0140), panoramic x-ray (D0330), extraction (D7210), implant (D6010), and bone graft at time of 
implant placement (D6104) provided on June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from March 5, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from March 5, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric care from March 
5, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health 
treatment beyond the date in question of March 5, 2022, forward. Our physician reviewer found the enrollee 
did not require inpatient mental health treatment beyond March 5, 2022, as she was not a danger to herself or 
others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment 
was taking place beyond the date in question. It did not appear that the services for the dates in question were 
reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from March 5, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from March 5, 
2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5211) and a partial lower 
denture (D5212). 
 
You asked the Plan to pre-approve a partial upper denture and a partial lower denture. You say that you are 
unable to eat, and it is causing additional health concerns. You are requesting approval for the requested dental 
services. The Plan denied your request. The Plan says the requested services exceed the maximum count 
allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a partial 
upper denture and a partial lower denture once every five plan years.  
 
 
 
 We looked at the file and Medicare rules. The records show you received a partial upper denture on March 17, 
2021, and a partial lower denture on March 30, 2021; therefore, you have exhausted your maximum benefit for 
these services. Based on this information, we decided that the Plan's rules for coverage of partial upper denture 
and lower partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a partial upper denture (D5211) and a partial lower denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on October 4, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that you were not scheduled for a refraction, but the 
technician felt it medically necessary due to the change in your vision after cataract surgery. The Plan denied 
your request. The Plan says this service is listed as an exclusion in your Evidence of Coverage. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-
rays (D0274) provided on August 11, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you told the provider that you 
are not able to pay out of pocket. You say that they did not verify your coverage. You also say that you did not 
realize that you had exhausted your benefit. The Plan denied your request. The Plan says 1 comprehensive oral 
evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded. 
 
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 and 1 comprehensive oral evaluation is 
covered every 3 plan years, the frequency limits has been exceeded. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on August 27, 2020. Therefore, we decided that the Plan does 
not have to pay for the comprehensive oral evaluation (D0150) and bitewing x-rays (D0274) provided on 
August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on October 11, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not advised 
that your insurance would not pay for these services prior to this date of service. You also say that you do not 
have the $142.00 for this payment. The Plan denied your request. The Plan says your dental maximum has been 
met. 
 
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 Plan offers a $1,000 annual dental 
benefit maximum. The record shows that you met the annual maximum benefit on April 16, 2021 and your 
annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the 
periodic oral evaluation (D0120) and prophylaxis (D1110) provided on October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory work provided by a network 
provider on August 13, 2021. 
 
You asked the Plan to waive the copayment for the laboratory work. You say that you should not be 
responsible for this bill because the clinic sent the sample to an out-of-network laboratory. You say the service 
should be covered. 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 $15 
copayment for each covered in-network laboratory service.  
 
 You have been asked to pay a $15 copayment for the laboratory work. The laboratory work falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. The record shows the 
provider was in-network. 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 laboratory work provided 
by a network provider on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that services were provided to the enrollee out of medical necessity. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider with no referral from an in-network provider. Also, the services provided 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 28, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the column chromatography rendered on June 4, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
The provider submitted a claim for procedure codes 82542 (column chromatography) and 80307 (presumptive 
drug testing). Code 82542 is a column II code with a modifier indicator of 1 when billed with column I code 
80307. Code 82542 was not billed with an appropriate modifier to allow for separate payment. The file does 
not support the use of the -59 modifier as a separate and distinct service. Therefore, we decided that the Plan 
does not have to pay for the column chromatography rendered on June 4, 2021.