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

 
We decided that the Plan does not have to waive the copayment for office visit provided on June 7, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 10% 
coinsurance for physician/practitioner services, including doctor's office visits. The allowed amount of this 
office visit total $124.52, resulting in a coinsurance amount of $12.28, which is less than $12.45. 
 
You have been asked to pay 10% coinsurance for office visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 office visit provided on June 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aortic aneurysm (AAA) screening (76706) 
provided on June 17, 2022. 
 
You asked the Plan to pay for the AAA screening. You say that this service was a medically necessary follow-
up to check for aneurysms and make sure the medication you are taking was the correct dosage. The Plan 
denied your request. The Plan says you received an abdominal aortic aneurysm screening on December 14, 
2020, and the health plan is not obligated to pay for a second abdominal aortic aneurysm screening. 
 The Plan must follow Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for abdominal aortic aneurysm (AAA). 
 
We looked at the file and Medicare rules. The record shows that you exhausted your AAA benefit on 
December 14, 2020. Based on this information, we decided that Medicare rules for coverage of the AAA 
screening have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal aortic 
aneurysm (AAA) screening (76706) provided on June 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic pathogen panel provided on May 11, 2022, billed 
with multiple codes. 
 
You asked the Plan to pay for the pathogen panel as billed. You say that this is a medically necessary panel 
which should be paid. The Plan denied your request. The Plan says there is no documentation of the medical 
necessity for this panel, and the panel has also been incorrectly unbundled. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pathogen panel as billed have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic pathogen panel provided on May 11, 2022, billed with multiple codes.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 27, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that this provider does not require a 
referral or authorization. The Plan denied your request. The Plan says this provider is not a network provider 
with the Plan. The Plan also says that these services are not urgent or emergent, nor were they approved in 
advance. 
 
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 subsequent nursing facility care provided on June 
27, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management provided to the enrollee 
on June 18, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or 
unrelated to the members terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management provided to the enrollee 
on June 18, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication management psychotherapy services 
provided on May 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medication management psychotherapy services. You say that you did not 
send the whole proof of payment, but are now submitting the itemized receipts. The Plan denied your request. 
The Plan says this service was rendered by an OON provider. The Plan also says that you did not obtain a prior 
authorization before receiving the service. 
 
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 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 the medication management psychotherapy 
services provided on May 4, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a below-knee alignable system, residual limb volume 
management system, and an ankle/foot system microprocessor power source. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the enrollee's current K3 foot is covered under warranty. 
 
The Plan must follow Medicare rules. The rules say that for durable medical equipment, if equipment or a 
device is replaced free of charge by the warrantor, no program payment may be made, 
 
We looked at the file and Medicare rules. The file shows that the enrollee has a current K3 foot that is covered 
under warranty. Based on this information, we decided that Medicare rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a below-knee alignable system, 
residual limb volume management system, and an ankle/foot system microprocessor power source.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 24, 2022, to 
January 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that this should be covered as it was medically 
necessary. The Plan denied your request. The Plan says there was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
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 home health services provided from January 24, 
2022, to January 31, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
tooth #30 (D6057). 
 
You asked the Plan to pre-approve the dental services. You say that the service is medically necessary. 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 date of service September 16 2022. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment  includes 
placement tooth #30 (D6057).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on June 17, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for each Medicare-covered emergency room visit. Emergency care refers to services that are 
furnished by a provider qualified to furnish emergency services and needed to evaluate or stabilize an 
emergency medical condition. 
 
You have been asked to pay a $120 copayment for emergency room services. This item/service falls within the 
Emergency 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 emergency room 
services on June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that due to the short time period, you were unable to get 
the authorization for the date of service. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan. The Plan also says that these services are not urgent or emergent, nor were they 
approved in advance. 
 
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 June 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 office visit provided on January 27, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder genetic testing services provided on March 1, 
2022. 
 
You asked the Plan to pay for the CxBladder genetic testing services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this testing is not covered 
for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a noncoverage policy in place for 
CxBladder testing. Based on this information, we decided that Medicare rules for coverage of the CxBladder 
genetic testing services have not been met. Therefore, we decided that the Plan does not have to pay for the 
CxBladder genetic testing services provided on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments on tooth #19, 21, 22, 27, 28, 
30, and 31 (D6056) and implant supported crowns on tooth #19, 21, 22, 27, 28, 30, and 31 (D6065). 
 
You asked the Plan to pre-approve abutments and crowns. You say that these services are medically necessary. 
The Plan denied your request. The Plan says prefabricated abutments (D6056) and implant supported crowns 
(D6065) are not covered by your 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 pre-approve 
prefabricated abutments on tooth #19, 21, 22, 27, 28, 30, and 31 (D6056) and implant supported crowns on 
tooth #19, 21, 22, 27, 28, 30, and 31 (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7140) for tooth #15. 
 
You asked the Plan to pre-approve the dental service. You say that your provider told you that you were 
covered for dental services, and it is necessary to have your tooth removed. The Plan denied your request. The 
Plan says the denial of authorization for this service is correct, because extractions are 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
extraction (D7140) for tooth #15.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 23, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 office visit provided on June 23, 2022, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have reimbursement for procedure code S9999 billed for date of service 
January 7, 2022 to January 25, 2022. 
 
You asked the Plan reimbursement for procedure code S9999. You say that you paid cash and was not aware 
that your insurance card may have paid. The Plan denied your request. The Plan says the billed code is invalid 
for Medicare purposes.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9999 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9999 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9999 have not been met. Therefore, we decided that the Plan does not 
have reimbursement for procedure code S9999 billed for date of service January 7, 2022 to January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the harness for upgrade to expandable controller, 
including all fasteners (CPT code E2313), expandable controller (E2377) and the ankle straps (K0108 X 2). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the items have not been met. Medicare guidance says that upgraded 
electronics (expandable controller and harness) are not medically necessary. They cannot be covered. The parts 
for the footplates are already included with the approved foot plates and cannot be requested separately. The 
code used for ankle straps does not match the item requested. Therefore, we decided that the Plan does not have 
to pre-approve the harness for upgrade to expandable controller, including all fasteners (CPT code E2313), 
expandable controller (E2377) and the ankle straps (K0108 X 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain or ceramic crown (D2740) for tooth number 
27. 
 
You asked the Plan to pre-approve a porcelain or ceramic crown (D2740) for tooth number 27. You say that 
you are appealing the denial of tooth number 27. The Plan denied your request. The Plan says the request for a 
crown for tooth number 27 is not medically necessary. 
 
 
 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 porcelain or 
ceramic crown (D2740) for tooth number 27 when the services are medically necessary and reasonable.  
 
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 a porcelain or ceramic crown (D2740) 
for tooth number 27. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the documentation supplied shows an incompletely filled root canal system on tooth number 27. Our 
physician reviewer also found that placing a crown on a tooth that has an improper or incomplete endodontic 
fill is not within the standard of care as the tooth has a very likelihood of failure due to periapical infection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a porcelain or ceramic crown (D2740) for tooth number 27 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a porcelain or ceramic crown (D2740) for 
tooth number 27.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 78815 billed for date of service September 2, 
2021. 
 You asked the Plan to pay for procedure code 78815. You say that you believe this claim should be reprocessed 
for payment. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
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 78815 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 
procedure code 78815 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 78815 billed for date of service September 2, 2021.