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

 
We decided that the Plan has to pay for the opioid treatment provided from February 8, 2022, to February 27, 
2022. 
 
You asked the Plan to pay for the opioid treatment. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the rendering provider is not listed on the 
Opioid Treatment Program directory. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The provider is listed as certified effective January 1, 2020, as an opioid 
treatment program provider, according to the Opioid Treatment Program Providers Directory at 
https://data.cms.gov/provider-characteristics/medicare-provider-supplier-enrollment/opioid-treatment-program-
providers/data. Therefore, we decided that the Plan has to pay for the opioid treatment provided from February 
8, 2022, to February 27, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an intraoral x-ray 
(D0220) provided on April 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services are medically necessary. 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 limited oral evaluation (D0140) and an intraoral x-ray (D0220) provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture-cast metal framework with resin 
base (D5214). 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this item is not covered 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 requested item is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a lower partial 
denture-cast metal framework with resin base (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D2391) provided on April 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 
 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 Plan's 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 dental services (D2391) provided on April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 11, 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 drug testing services provided on April 20, 2022. 
 You asked the Plan to pay for the services provided. You say that the records are sufficient for the services 
provided. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
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, the CPT Code Manual definition of code G0481 is definitive drug testing of 8-14 drug classes. We 
find that CPT code G0481 is not supported in the medical record. Specifically, there are no medical records 
from the treating physician to show that the drug testing of 8-14 drug classes was ordered based on clinical 
history and risk assessment. Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve second state implant surgery (D6011) for tooth #3, 5, 
14, desensitizing resin (D9911) for tooth #30, interim implant abutment placement (D6051) for tooth #3, 14, 
19, porcelain/ceramic crowns (D2740) for tooth # 4, 21, and core buildup (D2950) for tooth #21. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has a lot of missing teeth and 
struggles to eat. The Plan denied your request. The Plan says dental services D6011, D9911, and D6051 are not 
covered under the enrollee's supplemental benefits. The Plan also says that dental services D2740, and D2950 
have had their benefits 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, second state implant surgery (D6011), 
desensitizing resin (D9911), and interim implant abutment placement (D6051) are not among those covered 
under this benefit. For porcelain/ceramic crowns (D2740) and core buildup (D2950), certain limitations apply. 
The record shows your benefit for porcelain/ceramic crowns (D2740) and core buildup (D2950) was exhausted 
on date of service January 13, 2022. Therefore, we decided that the Plan does not have to pre-approve second 
state implant surgery (D6011) for tooth #3, 5, 14, desensitizing resin (D9911) for tooth #30, interim implant 
abutment placement (D6051) for tooth #3, 14, 19, porcelain/ceramic crowns (D2740) for tooth # 4, 21, and 
core buildup (D2950) for tooth #21.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a comprehensive periodontal evaluation (D0180) provided a 
participating provider on February 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says that your benefit for the requested item or service has already been 
exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for a comprehensive periodontal evaluation (D0180) 
provided by a participating provider on February 28, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
May 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel like the Plan should pay for this. 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 dental services provided by an out-of-network provider on May 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), a comprehensive oral evaluation 
(D0150), and bitewings (D0274), provided by an out-of-network provider on February 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that this provider was in-network at the time of these 
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 prophylaxis (D1110), a comprehensive oral evaluation (D0150), and bitewings (D0274), provided by 
an out-of-network provider on February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on April 7, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. You say that the enrollee is continuing to see 
their primary care physician they had prior to becoming effective with their new plan. The Plan denied your 
request. The Plan says no prior authorization was 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
hospital outpatient clinic visit. We found no exception that would require the Plan to pay for the hospital 
outpatient clinic visit. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic 
visit provided on April 7, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided from June 1, 2020, to June 
4, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare 
guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient services was not filed until April 13, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the outpatient services provided from June 1, 2020, to June 4, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert device. 
 
You asked the Plan to pre-approve a Life Alert device. You say that this is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says this device is statutorily not covered by 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that telephone alert systems will be denied as they are 
emergency communications systems and do not serve a diagnostic or therapeutic purpose. Based on this 
information, we decided that Medicare rules for coverage of a Life Alert device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a Life Alert device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for EKG provided on February 11, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for EKG. You say that you are appealing the claim payment denial. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not approved in advanced. 
 
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 EKG provided on February 11, 2022, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 44120, 44160, 49203 and 49560 billed on 
April 21, 2022. 
 
You asked the Plan to pay for procedure codes 44120, 44160, 49203 and 49560. You say that [Enter appellant's 
argument from appeal letter, e.g. "...you need SNF care."] The Plan denied your request. The Plan says 
procedure codes 44120, 44160, 49203 and 49560 are not supported by the medical records submitted. 
 
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, the CPT Code Manual definition of code 44120 is enterectomy, resection of small intestine; single 
resection and anastomosis. The CPT Code Manual definition of code 44160 is colectomy, partial, with removal 
of terminal ileum with ileocolostomy. The CPT Code Manual definition of code 49203 is excision or 
destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or 
retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less. The CPT Code Manual 
definition of code 49560 is repair initial incisional or ventral hernia; reducible. 
 
  We asked our coder 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 procedure codes 44120, 44160, 49203 and 49560. Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the operative report does not include documentation of an enterectomy, a partial 
colectomy, excision/destruction or a reducible initial incisional or ventral hernia repair. Therefore, these 
procedures cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 44120, 44160, 49203 and 49560 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 44120, 44160, 49203 and 49560 billed on 
April 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out of network Part B drugs provided on 
January 14, 2022. 
 
You asked the Plan to waive the coinsurance for out of network Part B drugs. You say that you met your out-
of-pocket maximum so this should be covered. The Plan denied your request. The Plan says at the time this 
claim was received your out-of-pocket maximum had not been reached. The Plan says the coinsurance applied 
is correct. 
 
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% 
coinsurance for out of network Medicare covered Part B drugs.  
 
 
 
 
 You have been asked to pay $2,837.69 which is 35% of the allowed amount for out of network Part B drugs. 
The allowed amount is $8,107.79 (35% x $8,107.79= $2,837.69). Out of network Part B drugs falls within the 
Medicare Part B Prescription Drugs 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 coinsurance for 
out of network Part B drugs provided on January 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that skilled nursing facility care is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF care and physical 
therapy, occupational therapy, and speech therapy can be provided on an inpatient basis at a SNF level of care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing needs and the enrollee does not require 
skilled nursing or therapy services on a daily basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac testing provided on April 2, 2022. 
 
You asked the Plan to waive the copayment for cardiac testing. You say that the billing is incorrect. The Plan 
denied your request. The Plan says the copayment applied is correct. 
 
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 $50 
copayment for diagnostic procedures and tests, including ultrasounds.  
 
You have been asked to pay $50 copayment for cardiac testing. Cardiac testing 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 cardiac testing provided on April 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
February 25, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure codes 99100 and 99140 are 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 codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
February 25, 2022.