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

 
We decided that the Plan does not have to pay for psychotherapy provided from July 21, 2021, to 
September 14, 2021. 
 
You asked the Plan to pay for psychotherapy. 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. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care 
from the effective date of election to the date of discharge or revocation. During the election, fee-for-service 
Medicare also covers attending physician services and all care unrelated to the terminal illness until the first 
day of the month following the month in which hospice was revoked or discharged. 
 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 psychotherapy provided from July 21, 2021, to  
September 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
April 29, 2022, to April 30, 2022. 
 
You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you had the procedure 
done prior and would like the copayment waived 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 $100 
copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, 
observation room or outpatient surgery services. 
 
You have been asked to pay a $100 copayment for an outpatient hospital visit. This item/service falls within the 
each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, observation room or 
outpatient surgery 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 an 
outpatient hospital visit provided on April 29, 2022, to April 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36410 billed for date of service February 1, 
2022. 
 
You asked the Plan to pay for procedure code 36410. You say that these services were coded and billed 
accurately. The Plan denied your request. The Plan says payment for code 36410 is bundled into payment for 
code 31500. 
 
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, we have confirmed that code 36410 
is a column II code to column I code 31500. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 36410 billed for date of service February 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a wheelchair-feature controller (K0108). 
 
You asked the Plan to pre-approve a controller. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that the requested item has been incorrectly unbundled 
from an approved expandable controller. 
 
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 rules specify that code K0108 should be used when individual 
components of a harness are replaced. The case record supports that the requested component is a replacement 
and not an initial issue. The Plan has not provided any other denial rationale. It is the Plan's responsibility to 
substantiate its denial with evidence. In this case, the Plan's denial has not been substantiated, so we must find 
in your favor. Therefore, we decided that the Plan has to pre-approve a wheelchair-feature controller (K0108).  
 
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 pre-approve other accessories, push rim cover Retrogit 24" E-Motion 
M25 (K0108) other accessories bracket set, Tilite Tra Deg Sturz (K0108) and other accessories Twion Torque 
Receivers, straight (K0108). 
 You asked the Plan to pre-approve the wheelchair accessories. You say that the enrollee cannot use their hands 
as needed. The power wheelchair would assist the enrollee withing having to use their hands as much. The Plan 
denied your request. The Plan says these items are bundled into an already approved code. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The requested items are already bundled within already approved 
code E0986, push-rim activated power assist option for a manual wheelchair. Based on this information, we 
decided that Medicare rules for coverage of the wheelchair accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve other accessories, push rim cover Retrogit 24" E-Motion 
M25 (K0108) other accessories bracket set, Tilite Tra Deg Sturz (K0108) and other accessories Twion Torque 
Receivers, straight (K0108).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services (80307) provided on May 11, 2022. 
 
You asked the Plan to pay for procedure code 80307. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that only one code from the 80305-80307 range may be 
reported per date of service for the same enrollee. The rules also 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 did not provide any evidence to show that another 
presumptive drug testing code (80305-80307) was already reported and paid to any provider for this enrollee 
on the date in question. Therefore, we decided that the Plan has to pay for the drug testing services (80307) 
provided on May 11, 2022.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery and occupational therapy 
rendered in an outpatient hospital setting. 
 
You asked the Plan to waive the copayment for the outpatient surgery and occupational therapy services. You 
say that your copayment for the hospital stay should only be $150. 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 $150 
copayment for inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $30 
copayment for occupational therapy  
 
 You have been asked to pay a $150 copayment for the surgical services, which fall within the outpatient 
hospital services benefit category. You have also been asked to pay a $30 copayment for the occupational 
therapy, which falls within the outpatient rehabilitation services benefit category. You are responsible for the 
full cost of the self-administered drugs provided on April 28, 2022, and April 29, 2022 ($3.20  2 = $6.40) 
because they are not covered benefits under Medicare guidelines. In total, you have been asked to pay a 
$299.83 copayment ($150 + $30 + $6.40 = $299.83). 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 
outpatient surgery and occupational therapy rendered in an outpatient hospital setting.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 12, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan for therapy guide provided on 
April 28, 2022. 
 
You asked the Plan to waive the copayment for a CT scan for therapy guide. You say that the scan was ordered 
by your provider as part of your treatment. You say that the Plan paid $0 towards the claim, and you would like 
a review. 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 $60 
copayment for each Medicare-covered radiation therapy service.  
 
 
  You have been asked to pay $48.91, which is less than the standard $60 copayment for a CT scan. This 
item/service 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 CT scan for therapy guide provided on April 
28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a periodic oral 
evaluation (D0120), and periodontal scaling and root planing (D4342) provided on May 18, 2022, and the 
topical application of fluoride varnish (D1206) provided on June 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 Plans 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 comprehensive oral evaluation (D0150), a periodic oral evaluation (D0120), and periodontal 
scaling and root planing (D4342) provided on May 18, 2022, and the topical application of fluoride varnish 
(D1206) provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician/practitioner service and lab 
service provided on June 23, 2022. 
 
You asked the Plan to waive the copayment for specialist's visit and lab service. You say that you should not 
have a copayment because you see your doctor as your primary care physician (PCP). 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 $35 
copayment for Medicare-covered benefits in a specialist setting. And you must pay $5 copayment for lab 
services performed in any other setting. 
 
You have been asked to pay $35 copayment and $5 copayment for specialist's visit and lab service. This 
item/service falls within the Medicare-covered benefits in a specialist setting and lab services performed in any other setting 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 physician/practitioner 
service and lab service provided on June 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan for therapy guide provided on May 11, 2022.

You asked the Plan to waive the copayment for a CT scan for therapy guide. You say that the scan was ordered by your provider as part of your treatment. You say that the Plan paid $0 towards the claim, and you would like a review. 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 $60 copayment for each Medicare-covered radiation therapy service. 

You have been asked to pay $48.91, which is less than the standard $60 copayment for a CT scan for therapy guide. This item/service 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 CT scan for therapy guide provided on May 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bandages (A6450) provided on May 22, 2022. 
 
You asked the Plan to pay for bandages. You say that this should be covered. The Plan denied your request. 
The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare makes a separate payment for supplies 
furnished in connection with a procedure only when one of the conditions listed in the rules section exists. 
 
We looked at the file and Medicare rules. The bandages at issues are supplies that do not meet criteria for 
separate payment. Based on this information, we decided that Medicare rules for coverage of bandages have 
not been met. Therefore, we decided that the Plan does not have to pay for bandages (A6450) provided on May 
22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) and an unspecified 
periodontal procedure (D4999) provided on June 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says oral hygiene instructions (D1330) and an unspecified periodontal 
procedure (D4999) 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 pay for oral 
hygiene instructions (D1330) and an unspecified periodontal procedure (D4999) provided on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation-diagnostic service provided by a dentist or 
physician other than requesting dentist or physician (D9310) on May 24, 2022. 
 
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 this service is not a covered benefit under 
your contractual policy. 
 
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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation-
diagnostic service provided by a dentist or physician other than requesting dentist or physician (D9310) on 
May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on Washington University on May 4, 
2022. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on May 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth with unusual complications 
(D7241), mandible closed reduction (D7640), general anesthesia first 15 minutes (D9222) and general 
anesthesia each subsequent 15-minute increment (D9223) provided from June 16, 2022, to July 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you spoke with the Plan and were assured that 
these services would be covered under your medical benefits, not dental. The Plan denied your request. The 
Plan says these services are not covered by the Plan's 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 the 
removal of impacted tooth with unusual complications (D7241), mandible closed reduction (D7640), general 
anesthesia first 15 minutes (D9222) and general anesthesia each subsequent 15-minute increment (D9223) 
provided from June 16, 2022, to July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0120), intraoral x-rays (D0220 and 
D0230), and a cleaning (D1110) provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to your dentist's office and there were 
two new dentists. You say that you were not told they were not in your plan. 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 Plans 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 an oral evaluation (D0120), intraoral x-rays (D0220 and D0230), and a cleaning (D1110) provided 
on April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for restorative foundation for an indirect restoration (D2949) 
provided on June 15, 2022. 
 
You asked the Plan to pay for restorative foundation for an indirect restoration (D2949). You say that your 
dentist determined the services were needed so you proceeded with the treatment. The Plan denied your 
request. The Plan says this service is not covered under the benefit package 
 
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 
restorative foundation for an indirect restoration (D2949) provided on June 15, 2022.