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

 
We decided that the Plan does not have to pay for external electrocardiographic recording (93243) provided on 
October 18, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for external electrocardiographic recording. You say that the item at issue was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-
network care have not been met. 
 
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 external electrocardiographic recording (93243) 
provided on October 18, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), bitewings 
(D0272), first intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), 
prophylaxis (D1110), resin-based composite of two surfaces (D2392), and resin-based composite of three 
surfaces (D2393) provided on October 22, 2021, and November 23, 2021. 
 
You asked the Plan to pay more for the comprehensive oral evaluation, bitewings, intraoral periapical x-rays, 
prophylaxis, and resin-based composites. You say that you were under the assumption that you were only 
supposed to pay for the office visit. You also say that you thought the fillings were covered at 50%, but you 
were overcharged. The Plan denied your request. The Plan says the correct cost sharing and coinsurance was 
assessed per your benefits to each service billed. 
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, you are responsible for a $15 copay for 
the oral exam and cleaning, and a $15 copay for x-rays. You are also responsible for a 50% coinsurance for 
each resin-based composite. Therefore, we decided that the Plan does not have to pay more for the 
comprehensive oral evaluation (D0150), bitewings (D0272), first intraoral periapical x-ray (D0220), two 
additional intraoral periapical x-rays (D0230 x2), prophylaxis (D1110), resin-based composite of two surfaces 
(D2392), and resin-based composite of three surfaces (D2393) provided on October 22, 2021, and November 
23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a visual field examination (92083) 
provided on August 31, 2021. 
 
You asked the Plan to waive the copayment for the visual field examination. You say that the services should 
be coveted as it was a follow-up visit. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $35 
copayment for Vision care.  
 
 
  You have been asked to pay a $35 copayment for a visual field examination. Visual field examinations fall 
within the Vision care 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 visual 
field examination (92083) provided on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a garment-type automatic external defibrillator (K0606) 
provided on August 19, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for a garment-type automatic external defibrillator. You say that the item at issue 
meets Medicare coverage criteria. The Plan denied your request. The Plan says rules for payment for out-of-
network care have not been met. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a garment-type automatic external defibrillator 
(K0606) provided on August 19, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) and the electrocardiogram (93000) 
rendered by the out-of-network (OON) provider on November 4, 2020. 
 
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 office visit (99213) and the electrocardiogram (93000) rendered by the out-of-
network (OON) provider on November 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 8, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that this is the correct POS code for this 
service. The Plan denied your request. The Plan says the reported POS code does not match where the sample 
was taken. 
 
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 Guardant360 testing 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 the Guardant360 testing provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), intraoral - 
periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image 
(D0230) provided November 17, 2021. 
 
You asked the Plan to pay for the bitewing x-rays and intraoral x-rays. You say that you were not told you 
would be charged for services until after they were rendered. The Plan denied your request. The Plan says you 
have exceeded the frequency limit for the bitewing x-rays and the intraoral x-rays are not covered under your 
benefits. Additionally, the Plan states that your claims of provider fraud are being separately addressed. 
 
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 Plan covers the bitewing 
x-rays once per calendar year.  
We looked at the file and Medicare rules. The Plan provided documentation showing that bitewing x-rays were 
previously covered on February 4, 2021. Based on this information, we decided that the Plan's frequency limit 
for coverage of the bitewing x-rays has been exceeded. Though the Plan offers dental benefits in excess of 
Medicare coverage, intraoral x-rays are not among those covered services. Therefore, we decided that the Plan 
does not have to pay for the bitewings - four radiographic images (D0274), intraoral - periapical first 
radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided 
November 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on August 30, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you are on a low 
fixed income and cannot afford the bills. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 
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. Therefore, we decided that the Plan does not have to waive the copayment for 
ambulance transportation services provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service (99441) 
rendered by the out-of-network (OON) provider on September 13, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the telephone evaluation and management service (99441) rendered by the out-of-
network (OON) provider on September 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ExoDx Prostate IntelliScore (EPI) genetic testing. 
 
You asked the Plan to pre-approve EPI genetic testing. The Plan denied your request. The Plan says the 
requested test is not medically necessary because there are no medical records supporting that the criteria for 
coverage have been met. 
 
The Plan must follow Medicare rules. Medicare rules say that EPI genetic testing is covered for certain clinical 
indications. Medicare rules also say that information must be provided to confirm that Medicare coverage 
criteria have been met. 
 
We looked at the file and Medicare rules. The case file did not include any medical records. The case file 
shows that the Plan made reasonable attempts to obtain medical records.  Based on this information, we 
decided that there is no evidence of the Medicare rules for coverage of EPI genetic testing having been met. 
Therefore, we decided that the Plan does not have to pre-approve ExoDx Prostate IntelliScore (EPI) genetic 
testing.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation from the hospital to a nursing facility 
provided on October 26, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that the enrollee had not yet been admitted to 
the SNF at the time of transport. The Plan denied your request. The Plan says that the ambulance transport is 
included in the SNF rate if the first or second character (origin or destination) of any HCPCS code ambulance 
modifier is D (diagnostic or therapeutic site other than P or H), and the other modifier (origin or 
destination) is N (SNF). 
 
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. We find that the Plan's denial rationale does not apply to the services at issue. 
Neither the origin nor destination for this transport was marked as "D". This was a trip from a discharging 
hospital for admission to a SNF, which is payable per the rules cited. The Plan provided no evidence that would 
suggest that this transport would be included in Part A payment to the hospital or SNF. Therefore, we decided 
that the Plan has to pay for the ambulance transportation from the hospital to a nursing facility provided on 
October 26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network 
(OON) provider on October 8, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on October 8, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external electrocardiographic recording (93243) rendered 
by the out-of-network (OON) provider on October 18, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the external electrocardiographic recording (93243) rendered by the out-of-network 
(OON) provider on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nuclear medicine study of the heart 
provided on November 10, 2021. 
 
You asked the Plan to waive the copayment for a nuclear medicine study. You say that you were told there was 
no cost for this test. 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 $325 
copayment for diagnostic radiology services, including nuclear cardiac imaging.  
You have been asked to pay a $325 copayment for a nuclear medicine study. A nuclear medicine study 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 a nuclear medicine study of the heart provided on November 10, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an ultrasound provided on November 30, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you were not given the right 
information, that the copayment should be $25. The Plan denied your request. The Plan says that the 
copayment amount charged is correct. 
 
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. The Plan has not sufficiently provided us with an appropriate Evidence of 
Coverage (EOC) to support their decision. Therefore, we decided that the Plan has to waive the copayment for 
an ultrasound provided on November 30, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330), comprehensive oral evaluation 
(D0150), and filling (D2391) provided from October 25, 2021, to November 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you cannot keep paying out money that you do 
not have. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 and the services are listed as covered, 
the frequency limits have been exceeded. The record shows that the Plan paid for a complete series x-ray and 
comprehensive oral evaluation that you received on October 24, 2019.  The record also shows that the Plan paid for 2 fillings that you received on April 14, 2021. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330), comprehensive oral evaluation (D0150), and filling (D2391) provided from October 25, 2021, to November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing 
x-rays (D0274) provided on October 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that these preventive services should be paid in full. 
The Plan denied your request. The Plan says there is an annual maximum benefit of $1,500 for dental services. 
The Plan also says that the maximum benefit 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 the services are listed as covered, 
the annual maximum benefit of $1,500 has been exceeded. 
 Date of Service Plan Paid 
4/6/2021 $106 
9/2/2021 $113 
1/28/2021 $225 
5/13/2021 $452.50 
4/28/2021 $106.50 
10/7/2021 $716 
TOTAL: $1,719 
 
Additionally, the Evidence of Coverage clearly states that after the annual maximum is exhausted, any 
remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the oral 
exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin fillings (D2331, D2392, D2392) provided on July 12, 2021. 
 
You asked the Plan to pay for the fillings. You say that you were assured these services would be covered when 
you went to have this treatment done, and you are frustrated that you first received a bill five months afterward. 
The Plan denied your request. The Plan says you received four fillings on the date in question. Your dental 
benefit can cover one filling per calendar year. One filling has been paid, but the remaining three exceeded the 
limitations of your benefit and are your responsibility. 
 
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 Plan can cover one 
restoration (filling) per year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the fillings are requested in a 
frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the resin fillings (D2331, D2392, D2392) provided on July 12, 2021.  Your complaint about potential misinformation from a Plan-contracted provider 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.