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

 
We decided that the Plan does not have to pay for an office visit provided on September 27, 2022. 
 
You asked the Plan to pay for an office visit. You say that these services were medically neccesary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2740), core buildup (D2950), and endodontic 
therapy (D3310) for tooth #27 and #28 provided on September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you told the provider's office not to go over the 
benefit limit. The Plan denied your request. The Plan says your annual dental benefit for the year 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. On January 
24, 2022, the Plan paid $61 for dental services. On July 13, 2022, the Plan paid $47 for dental services. On 
August 11, 2022, the Plan paid $2,163 for dental services. On August 31, 2022, the Plan paid $300 for dental 
services. On September 7, 2022, the Plan paid $429 for dental services. For the year the Plan paid a total of 
$3,000 ($61 paid + $47 paid + $2,163 paid + $300 paid + $429 paid) for dental services. The record shows 
your annual dental benefit for the year was exhausted on date of service September 7, 2022. Therefore, we 
decided that the Plan does not have to pay for the crowns (D2740), core buildup (D2950), and endodontic 
therapy (D3310) for tooth #27 and #28 provided on September 7, 2022.  
 
Your complaint about the provider rendering dental services over your benefit limit 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for risk assessment and documentation (D0603), an assessment 
(D0191), and a 2D oral image (D0350), provided on September 3, 2021, to October 5, 2021. 
 
You asked the Plan to pay for risk assessment and documentation, an assessment, and a 2D oral image. You 
say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered 
dental services are not covered. 
 
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 risk 
assessment and documentation (D0603), an assessment (D0191), and a 2D oral image (D0350), provided on 
September 3, 2021, to October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on September 26, 
2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that the facility is responsible for 
obtaining prior authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for domiciliary or rest home 
visit provided on September 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye procedure provided on January 13, 2022. 
 
You asked the Plan to pay for an eye procedure. You say that you did not think this procedure needed prior 
authorization. This was medically necessary. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an eye procedure 
provided on January 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on September 17, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you 
belong to the ambulance service, you pay them yearly, and never get a bill when you call them to take you to 
the hospital. You also say that you always go to the hospital, and have never been treated in your house. The 
Plan denied your request. The Plan says the claim processed correctly according to the contract and Medicare 
guidelines, and there was no plan error. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
  The ambulance company did not provide transport services on September 17, 2022. Specifically, the record 
shows that you refused transport and accepted treatment. The ambulance benefit is a transportation benefit. 
When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided 
that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) 
provided on September 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation 
(A0427) provided on August 15, 2022. 
 
You asked the Plan to waive the copayment for the emergency ambulance transportation. You say that you 
were at the physician's office when you fainted. You also say that the hospital did not give you any other 
options of transportation, and you understand the doctor's office called for the ambulance. 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 for each one-way Medicare-covered ground trip under the Ambulance Services benefit category. 
 
 
 
 You have been asked to pay a $250 copayment for the emergency ambulance transportation. This service 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 
the emergency ambulance transportation (A0427) provided on August 15, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve gastric bypass surgery (43645). 
 
You asked the Plan to pre-approve gastric bypass surgery. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that laparoscopic sleeve gastrectomy is covered when 
specific criteria are met. 
 
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 gastric bypass surgery. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the enrollee is requesting a 
conversion from sleeve gastrectomy to gastric bypass for control of post sleeve gerd and hiatal hernia repair. 
Conversion to gastric bypass is a standard treatment for post sleeve gastrectomy gastroesophageal reflux 
disease (gerd). This is not for weight loss, but for control of GERD refractory to medication use. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of gastric bypass surgery have been met. Therefore, we decided that the Plan has 
to pre-approve gastric bypass surgery (43645).  
 
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 a comprehensive oral evaluation (D0150) provided on 
November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like this insurance company is careless. 
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 April 14, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D photographic images (D0350), a pre-diagnostic test 
(D0431), and a diagnostic cast (D0470), provided on October 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like your visit and procedures 
covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the 2D photographic images, pre-diagnostic test, and diagnostic cast are not covered by the Plan in-
network or out-of-network. 
 
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 2D 
photographic images (D0350), a pre-diagnostic test (D0431), and a diagnostic cast (D0470), provided on 
October 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87641, 87653, and 87798 
billed for date of service August 22, 2022. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87641, 87653, and 87798. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says payment for codes 87150, 87481, 
87641, 87653, and 87798 is bundled into payment for codes 87801 and 87500. 
 
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 87150, 
87481, 87641, 87653, and 87798 is a column II code to column I codes 87801 and 87500. 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 codes 
87150, 87481, 87641, 87653, and 87798 billed for date of service August 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 28, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81291, 81328, 81355, 0031U, 0032U and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 28, 2022, billed with codes 81227, 81230, 81231, 81232, 81291, 81328, 81355, 0031U, 0032U and 
0033U.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns (D2791) for tooth #20 and #21 provided by an 
out-of-network provider on October 25, 2022, and October 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to cover the denied 
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 the crowns (D2791) for tooth #20 and #21 provided by an out-of-network provider on October 25, 
2022, and October 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care services provided on November 10, 2022. 
 
You asked the Plan to pay for transitional care services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for transitional care services 
provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), an intraoral 
radiographic image (D0210), and a cleaning (D1110) provided by an out-of-network provider on October 18, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you went to the dentist for only a cleaning 
and the provider decided to do a comprehensive. 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 comprehensive oral evaluation (D0150), an 
intraoral radiographic image (D0210), and a cleaning (D1110) provided by an out-of-network provider on 
October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital inpatient or observation discharge day management 
(code 99239) provided on August 26, 2022. 
 
You asked the Plan to pay for hospital inpatient or observation discharge day management. The Plan denied 
your request. The Plan says per review of the claims history, code 99238 was already billed by the provider of 
same billing group under referring claim# 820222520144636 on date of service August 27, 2022, which was 
processed and paid on September 14, 2022. Also, the documentation did not indicate that the member was 
discharged on date of service August 26, 2022, or that discharge day management was performed on date of 
service this date of service by the billing provider. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of hospital inpatient or observation 
discharge day management have been met. Specifically, there are no medical records provided. Therefore, we 
decided that the Plan does not have to pay for hospital inpatient or observation discharge day management 
(code 99239) provided on August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99190 and 99192 provided on April 27, 
2022. 
 
You asked the Plan to pay for procedure codes 99190 and 99192. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are included in the 
payment made to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. 
 The file shows that the enrollee was an inpatient at the time the services were provided. The facility must 
furnish all necessary covered services to the beneficiary either directly or under arrangements made with 
outside providers. This service was provided via arrangement of the facility. Payment for this service would 
have been included under the facility claim. Payment to you for this service is the responsibility of the facility. 
Therefore, we decided that the Plan does not have to pay for procedure codes 99190 and 99192 provided on 
April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of lateral exostosis (maxilla or mandible) (D7471) 
provided on April 20, 2022. 
 
You asked the Plan to pay for the removal of lateral exostosis (maxilla or mandible) (D7471). You say that this 
should be covered as the service is medically necessary. 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 removal 
of lateral exostosis (maxilla or mandible) (D7471) provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0364) provided on October 7, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental services provided were paid to the 
provider who performed the service. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the cone beam is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone 
beam (D0364) provided on October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth service provided on October 27, 2022. 
 
You asked the Plan to pay for telehealth service. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for telehealth service 
provided on October 27, 2022.