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

 
We decided that the Plan does not have to pay for the debridement of an open wound (97597) provided on 
March 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 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 debridement of an open wound (97597) provided on March 
14, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to additionally reimburse you for a crown (D2740) and core buildup 
(D2950) for tooth #8 provided on April 15, 2022. 
 
You asked the Plan to additionally reimburse you for the dental services. You say that you should receive the 
full $1,000 reimbursement for the dental services. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 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 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 50% 
coinsurance for preventive dental services and comprehensive dental services. You pay for the services up-
front, and we will reimburse you 50% of the amount you paid, up to a maximum yearly reimbursement of 
$1,000 every year for non-Medicare covered preventive dental services and non-Medicare covered 
comprehensive dental services combined. The total allowed amount was $1,022.25 with a coinsurance of 
$511.12 ($1,022.25 total amount x 50% coinsurance). The Plan total reimbursement towards the dental services 
was $511.12. 
 
You have been asked to pay a 50% coinsurance for the dental services. This item/service falls within the Dental 
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 additionally reimburse you for a crown (D2740) and 
core buildup (D2950) for tooth #8 provided on April 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0245U billed for services provided on May 
23, 2022. 
 You asked the Plan to pay for procedure code 0245U. You say that the tests aid in the diagnosis of the 
enrollee's condition. The Plan denied your request. The Plan says the rules for payment have not been met. 
 
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 0245U is a column II code to column I code 0018U with a modifier 
indicator of 0. The column II code is therefore not payable. Based on this information, we have decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0245U billed for services provided on May 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140) and a periapical x-
ray (D0220) provided on August 23, 2022, and the extraction of tooth #11 and 12 (D7140) provided on 
September 1, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told your dentist was in-
network. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a limited oral evaluation (D0140) and a 
periapical x-ray (D0220) provided on August 23, 2022, and the extraction of tooth #11 and 12 (D7140) 
provided on September 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
May 18, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date of service May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial. 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, for 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 May 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing, 22 or more drug classes (G0483) 
provided November 9, 2021. 
 
You asked the Plan to pay for the drug testing. You say that your clinics complete presumptive urine drug 
testing for medical necessity for the patients who are prescribed opioids as part of their clinical regulations. The 
Plan denied your request. The Plan says ordering a multi-class panel of definitive (confirmation) urine drug 
tests that are not used in clinical management, exceeds the needs of the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 pay for the drug testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the appellant states their clinics complete presumptive urine drug testing for 
medical necessity for the patients who are prescribed opioids as part of their clinical regulations. Presumptive 
urine drug testing for all twenty-two classes of opioids is necessary for each of the pain patients in order to 
prevent over prescribing opioids and to confirm the patients are not abusing street drugs while taking their 
opioid prescriptions. They believe they should be proactive in the screening/confirmation process for addition 
narcotics in the chronic pain patients. There are 14 drugs tested in the confirmation that are not tested in the 
presumptive screening. The documentation shows that presumptive screening test results which are partially 
inconsistent with prescription medications, or history and expected results. Definitive confirmation testing was 
medically necessary for only 1 drug class: Cannabinoids, natural. The review has determined that the medical 
records provided did not meet the medically necessary requirements listed in the LCD for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for definitive drug testing, 22 or more drug classes (G0483) provided November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and core buildup, including any pins when 
required provided on June 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed a root canal due to a bacterial 
infection. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
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 pay for the crown 
and core buildup, including any pins when required provided on June 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device provided on June 2, 2022. 
 
You asked the Plan to pay for the TENS device. You say that you would like this claim reprocessed based on 
the medical records. The Plan denied your request. The Plan says the provider has confirmed they did not order 
the supplies in question. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the medical records do not include documentation that the provider discussed the 
medical necessity of the ordered supplies with the enrollee. Therefore, we decided that the Plan does not have 
to pay for the transcutaneous electrical nerve stimulation (TENS) device provided on June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99222 billed for date of service June 24, 
2022. 
 
You asked the Plan to pay for procedure code 99222. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says there are no modifiers allowed with the 
code edit. 
 
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 99222 
is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99222 billed for date of service June 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of tooth #29 (D7210) provided on August 16, 
2022. 
 
You asked the Plan to pay for an extraction. You say that you were not put to sleep for the extraction. The Plan 
denied your request. The Plan says an extraction (D7210) is 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 the 
extraction of tooth #29 (D7210) provided on August 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) and a complete 
maxillary denture (D5110) provided on June 30, 2022. 
 
You asked the Plan to pay for a mandibular partial denture (D5214) and a complete maxillary denture (D5110). 
You say that that you subscribed to the Plan, the person that oriented you indicated the Plan would cover dental 
dentures. The Plan denied your request. The Plan says there is no coverage for a mandibular partial denture 
(D5214) and a complete maxillary denture (D5110). The Plan also says the member did not contact the Plan 
prior to the date of service to verify benefits and provider eligibility. 
 
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 
mandibular partial denture (D5214) and a complete maxillary denture (D5110) provided on June 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided on March 29, 2022, to 
April 21, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you dont know why your 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 $125 
copayment for Skilled nursing facility (SNF) care. 
 
You have been asked to pay a $125 copayment for SNF care. This item/service falls within the Skilled nursing 
facility (SNF) 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. You have been asked to pay a total of $375 ($125 x 3 days) for your SNF stay. Therefore, we 
decided that the Plan does not have to waive the copayment for SNF care provided on March 29, 2022, to April 
21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) provided on March 16, 2022. 
 
You asked the Plan to pay for the hearing aids. You say that you were advised you could check other sources 
for hearing aids, which you did. You also say that the provider you went to is ranked very highly for hearing 
aids and service levels. The Plan denied your request. The Plan says these hearing aids were purchased from a 
non-network provider. 
 
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 when using a Plan-approved Network Provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5261) provided on March 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for surgical procedures provided on July 6, 
2022, to July 20, 2022. 
 
You asked the Plan to waive the copayment for surgical procedures. You say that you feel you should be 
charged a copayment for the 3 follow up visits. 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 $300 
copayment for each visit for surgical procedure for outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay $300 copayment for each visit for surgical procedure for surgical procedures. This 
item/service 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 surgical 
procedures provided on July 6, 2022, to July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to additionally reimburse you for the topical application of fluoride 
(D1206), a cleaning (D1110), a crown (D2740), and the core buildup (D2950) for tooth #5 provided on June 7, 
2022. 
 You asked the Plan to additionally reimburse you for the dental services. You say that you should have only 
been responsible for less than what was charged. The Plan denied your request. The Plan says this cost sharing 
was charged correctly and the enrollee was reimbursed the proper amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for cleaning. The contract also says that enrollees must pay a $425 copayment for a crown and that 
the contract dentist may charge an additional fee not to exceed $325.00 in addition to the listed copayment for 
specialized technique or materials. The contract also says that enrollees must pay a $50 copayment for core 
buildup. The total copayment amount for the cleaning was $15. The total copayment amount for the crown was 
$750. The total copayment amount for the core buildup was $50. The total amount for the non-covered 
application of fluoride was $39. The total amount the enrollee is responsible for is $854 ($15 copayment + 
$750 copayment +$50 copayment + $39 non-covered. The total amount the provider charged was $1,109 and 
the total amount of reimbursement was $255 ($1,109 total amount - $854 enrollees responsibility). 
 
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. 
 
You have been asked to pay $854 for the copayments and enrollee responsibility for the dental services. This 
item/service falls within the description of benefits and copayments benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. Though the Plan offers a dental 
benefit in excess of Medicare coverage, the application of fluoride is not among those covered under this 
benefit. 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 additionally reimburse you for the topical application of 
fluoride (D1206), a cleaning (D1110), a crown (D2740), and the core buildup (D2950) for tooth #5 provided on 
June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care provided from February 15, 
2022, to March 11, 2022. 
 
You asked the Plan to waive the copayment for wound care. You say that you feel you were given the wrong 
information. 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 $250 
copayment per visit for in-network outpatient surgery/outpatient hospital.  
 
You have been asked to pay a $250 copayment per visit for wound care. You are being asked to pay $750 
($250 x 3 visits = $750).  Wound care is an outpatient surgery. This item/service falls within the in-network 
outpatient surgery/outpatient hospital 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 care provided from February 15, 2022, to March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92004) and fundus photography with 
interpretation and report (92250) provided on July 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye exam and fundus photography. The Plan denied your request. The Plan 
says you received these services from an OON provider. The Plan also says that you did not request or receive 
prior authorization from the Plan. 
 
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 eye exam (92004) and fundus photography 
with interpretation and report (92250) provided on July 3, 2022, by an out-of-network (OON) provider.