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

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #3. 
 
You asked the Plan to pre-approve the crown. You say that your provider said you need the crown to fix tooth 
#3. The Plan denied your request. The Plan says your plan does not cover this procedure. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740) for tooth #3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve canal preparation and fitting of preformed dowel or post 
(D3950) provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that you need these services to be provided. The 
Plan denied your request. The Plan says D3950 is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve canal 
preparation and fitting of preformed dowel or post (D3950) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), extraction (D7210), and 
removal of bone oral surgery (D7999) provided on October 13, 2021. 
 
You asked the Plan to pay for oral surgery. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says removal of bone oral surgery (D7999) is not covered by your 
supplemental dental benefits. 
 
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 a limited 
oral evaluation (D0140), extraction (D7210), and removal of bone oral surgery (D7999) provided on October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on September 28, 2021. 
 
You asked the Plan to pay for an evaluation. You say that you were unaware that this service was not covered. 
The Plan denied your request. The Plan says a comprehensive periodontal evaluation (D0180) is not covered by 
your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and panoramic x-ray 
(D0330) provided on November 4, 2020. 
 
You asked the Plan to pay for the dental services. You say that the provider never told you that they were out-
of-network. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the battery for use in hearing device (V5266) and Hearing 
aid, digital, binaural, bte (V5261) provided October 7, 2021. 
 
You asked the Plan to pay for the hearing services. You say that a payment was made but was recouped. 
Updated records are attached to make this payment again. The Plan denied your request. The Plan says the 
benefit maximum has been exhausted. This service is not covered by Medicare. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only the Plan pays up to $2,000 allowance for hearing aids every 3 years.  
 
We looked at the file, and the Plan's rules. V5266 is assigned a status code N = non-covered service. The Plan 
had overturned and paid the total $2,000 allowance and the benefit is exhausted. Based on this information, we 
decided that the Plan's rules for coverage of the hearing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the battery for use in hearing device (V5266) and Hearing aid, digital, 
binaural, bte (V5261) provided October 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a fluciclovine f-18 diagnostic injection 
provided with a computed tomography (CT) scan on July 22, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were not aware of the 
coinsurance for the diagnostic injection. The Plan denied your request. The Plan says the correct coinsurance 
was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for each medical supply, including chemical agents used in certain diagnostic procedures.  
 
You have been asked to pay $1,094.40, which is 20% of the allowed amount for the injection ($5,472.00 
allowed amount x 20% coinsurance = $1,094.40). The injection 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 coinsurance 
for a fluciclovine f-18 diagnostic injection provided with a computed tomography (CT) scan on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the gym membership purchased on December 12, 
2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that you have exhausted the allowable benefit 
for the gym membership purchased in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that you have exhausted the allowable benefit 
for the gym membership purchased in this case. The Plan says that reimbursement was issued to you previously 
in the same calendar year for a gym membership purchased on February 19, 2021. However, the Plan has not 
provided proof of this reimbursement issued to you. The Plan has not substantiated their denial; therefore, we 
must find in your favor. Therefore, we decided that the Plan has to issue reimbursement for the gym 
membership purchased on December 12, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 24, 2021. 
 
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 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 April 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Wound debridement on February 07, 2022. 
 
You asked the Plan to waive the copayment for wound debridement. You say that you are appealing the 
amount being charged. The Plan denied your request. The Plan says the cost-sharing you are being charged is 
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 $225 
copayment for each Medicare-covered outpatient hospital visit. We cover medically-necessary services you get 
in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered services 
include, but are not limited to the following and cost sharing may apply: Services in an emergency department 
or outpatient clinic, such as observation services or outpatient surgery. 
 
 
 
  
You have been asked to pay a $225 copayment for wound debridement. Wound debridement 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 Wound 
debridement on February 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit with an out-of-
network (OON) provider on February 8, 2022. 
 
You asked the Plan to waive the deductible for the OON office visit. You say that you saw this provider before 
and only had a $40 specialist copayment. The Plan denied your request. The Plan says the correct amount was 
applied to your deductible. 
 
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 $750 deductible which applies to certain items and services.  
 
The OON office visit you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $750 deductible which applies to certain items and services. The file 
shows that the Plan also verified the provider is not a network provider. This cost sharing is a contractual 
obligation that had not been met at the time the OON office visit was received on February 8, 2022. Therefore, 
we decided that the Plan does not have to waive the deductible for a specialist office visit with an out-of-
network (OON) provider on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the infrared therapy (97026) 
provided on October 8, 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 these services are not a covered benefit under 
the enrollees contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203) and the infrared therapy (97026) provided on  
October 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a fluciclovine f-18 diagnostic injection 
provided with a computed tomography (CT) scan on January 14, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you are on social security and 
cannot afford the coinsurance. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for medical supplies, including chemical agents used in certain diagnostic procedures.  
 
You have been asked to pay $494.40, which is 10% of the allowed amount for the injection ($4,944.00 allowed 
amount x 10% coinsurance = $494.40). The injection 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 coinsurance for a 
fluciclovine f-18 diagnostic injection provided with a computed tomography (CT) scan on January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81286, 81413, 81414, 81442, 81161, 
and 81479) provided on December 9, 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 the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (81286, 81413, 81414, 81442, 81161, and 81479) provided on December 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for chemotherapy infusion administration 
provided on February 3, 2022, and March 3, 2022. 
 
You asked the Plan to waive the copayments for the chemotherapy administration. You say that there were no 
office visits with the infusion. 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 $30 
copayment for chemotherapy administration or infusion.  
 
You have been asked to pay a $30 copayment for each chemotherapy administration, for a total of $60. The 
chemotherapy administration falls within the Medicare Part B Prescription Drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for chemotherapy infusion administration provided on February 3, 
2022, and March 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a spinal fusion procedure performed on 
November 23, 2021. 
 
You asked the Plan to waive the copayment for the spinal fusion. You say that this was the same surgery as the 
one on November 17, 2021, and should not have a separate copayment. 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 $550 
copayment for outpatient surgery in an outpatient hospital facility.  
 
The file shows that this procedure was performed on a separate part of the spine, and also performed on a 
different date. Therefore, you have been asked to pay a $550 copayment for the spinal fusion. The spinal fusion 
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 spinal 
fusion procedure performed on November 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services (G0378) provided from January 15, 
2022, to January 17, 2022. 
 
You asked the Plan to pay for the outpatient 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. 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 G0378 is Hospital observation service, per hour. 
We find that CPT code G0378 is not supported in the medical record. Specifically, it is not appropriate to bill more than one line of observational services per claim. In this case multiple lines of CPT code G0378 have 
been billed. This does not meet Medicare guidelines for billing or reimbursement consideration. Based on this 
information, we decided that Medicare rules for coverage of the outpatient services have not been met. 
Therefore, we decided that the Plan does not have to pay for the outpatient services (G0378) provided from 
January 15, 2022, to January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. 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 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 March 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient surgery services provided on 
October 21, 2020 and April 13, 2021. 
 
You asked the Plan to waive the copayments for outpatient surgery. You say that each visit with this doctor has 
been $40 copayment and you should only be required to pay this amount for these services. The Plan denied 
your request. The Plan says the copayment amounts you are being charged are 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 $275 
copayment for in-network outpatient surgery. For date of service October 21, 2020, you have been asked to pay 
the allowed amount of $177.39 because it is less than the $275 copayment amount. For date of service April 
13, 2021, you have been asked to pay $275 copayment. Therefore, your total copayment responsibility is 
$452.39. 
 You have been asked to pay $275 copayment or less for outpatient surgery. Outpatient surgery 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 copayments for outpatient surgery 
services provided on October 21, 2020 and April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paravertebral facet joint injections (64494-RT and 
64494-LT) provided on March 10, 2022. 
 
You asked the Plan to pay for codes 64494-RT and 64494-LT. 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. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of codes 
64494-RT and 64494-LT have not been met. Code 64494 has a bilateral surgery indicator of 1 and must be 
reported with 1 unit of service and modifier 50 (bilateral modifier). Therefore, we decided that the Plan does 
not have to pay for the paravertebral facet joint injections (64494-RT and 64494-LT) provided on March 10, 
2022.