Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on April 26, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that the service should be covered. The Plan denied 
your request. The Plan says you did not contact the Plan's hearing vendor to access your hearing aids. 
 
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 plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when contact the Plan's hearing vendor to access the routine hearing exam and supplemental 
hearing aid benefits.  
 
We looked at this physician's review, 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 provided on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer crown (D6750), a tooth extraction (D7210) 
and a pontic - porcelain fused to high noble metal (D6240). 
 
You asked the Plan to pre-approve dental services. You say that you need the crowns that were requested by 
his dentist. You also say that due to having a dual plan, the services requested should be covered. The Plan 
denied your request. The Plan says the enrollee's dental benefits are through their Medicaid coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve a retainer crown 
(D6750), a tooth extraction (D7210) and a pontic - porcelain fused to high noble metal (D6240).
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the EKG. We decided that the Plan does not have to waive the coinsurance that it should have charged for the EKG.
You asked the Plan to waive the copayment for the EKG. You say that you shouldn't have to pay this cost sharing because you didn't order this test and you don't know the doctor who performed it. The Plan says that you were charged this cost sharing correctly.
We decided that the Plan has to waive the copayment for the EKG.
The rules say that plans must clearly disclose cost sharing obligations to their enrollees. In this case, the Plan contends that since the allowed amount for the EKG is less than the $30 copayment for physician services, you are responsible for the full amount. We don't find this argument persuasive. You had an EKG, which is an outpatient test. A $30 copayment does not apply to outpatient tests. Therefore, we decided that the Plan has to waive the copayment for the EKG.
We also decided that the Plan does not have to waive the coinsurance that it should have charged for the EKG.
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 20%
coinsurance for diagnostic tests such as an EKG. The allowed amount for this test is $8.88, so 20% of that amount is $1.78. This is all that the Plan should have charged you for this service. Therefore, we decided that the Plan does not have to waive the coinsurance it should have charged for the EKG.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (80050) rendered by the out-of-
network (OON) provider on April 23, 2021. 
 
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 the service was rendered by an out of network 
provider, without prior authorization. 
 
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 had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (80050) rendered by the out-of-network (OON) provider on 
April 23, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the heart.
You asked the Plan to pre-approve the scan. You say that this is medically necess The Plan denied your
request. The Plan says that the health plan does not cover the requested study.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 the scan. Our reviewer says that the
requested scan is medically reasonable and necessary. Our physician reviewer found while you do not show
physical signs of cardiac disease, you do have a documented first degree AV block on your EKG in July 2020.
This EKG finding may be associated with heart disease, including coronary disease. As such, this would be a
symptom which would qualify for a diagnostic CT calcium scoring and thus should be a covered benefit.
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 scan have been met. Therefore, we decided that the Plan has to pre-approve
CT scan of the heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periapical radiographic images (D0220 and D0230) provided 
by a participating provider on June 18, 2021. 
 
You asked the Plan to pay for periapical radiographic images. You say that you would like the Plan to pay for 
these charges. The Plan denied your request. The Plan says these are not covered services. 
 
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. 
 
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 periapical 
radiographic images (D0220 and D0230) provided by a participating provider on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392) provided on June 9, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the resin-based composite. You say that you know this service was rendered by 
an OON provider, but you would like the claim to be properly paid. The Plan denied your request. The Plan 
says this service was rendered by an OON provider. The Plan also says that the OON provider is allowed to bill 
the difference between the allowed amount and their billed amount to you. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the $96.80 that 
was applied toward the deductible, plus the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2392) provided on 
June 9, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Imfinzi.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has non-small cell lung
cancer (NSCLC) of the right lower lube with solitary metastatses to the brain. Patients with oligometastatic
non-small cell lung cancer are often treated with curative intent. The enrollee's solitary brain tumor was treated
with cyberknife and she is now being treated as a stage IIIB, having completed concurrent chemotherapy and
radiation. The standard of care would be to complete a year of durvalumab (Imfinizi) as long as follow-up
scans show at least stable disease. The service is reasonable and medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to preapprove
Imfinzi.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services provided on June 16, 2021. 
 
You asked the Plan to pre-approve the services provided. You say that your wife did not have to pay for 
chiropractor services in the past. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The file shows that an office visit, mechanical traction therapy, electric stimulation, and massage therapy were 
provided. Services other than manual manipulation of the spine are not covered when provided by a 
chiropractor. Therefore, we decided that the Plan does not have to pre-approve chiropractic services provided 
on June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to waive the $50 copayment for the resin-based composite. We decided that the
Plan does not have to pay for the remaining $119 for the resin-based composite.
You asked the Plan to pay more for the resin-based composite. You say that you paid your $50 deductible
when you paid the first $50 for this service. You also say that you feel that you were overcharged, and should
not have to pay this much. The Plan says that this claim was processed and paid correctly.
We decided that the Plan has to waive the $50 copayment for the resin-based composite.
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 EOC does not clearly state that an office visit copay would be applied even if no office visit charge was
billed, nor that a single service would be subject to both a copayment plus coinsurance. The enrollee cannot
reasonably be asked to pay more than $119 for this service. Therefore, we decided that the Plan has to waive
the $50 copayment for the resin-based composite.
We also decided that the Plan does not have to pay for the remaining $119 for the resin-based composite.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for the remaining
$119 balance for the resin-based composite. Therefore, we decided that the Plan does not have to pay for the
remaining $119 for the resin-based composite.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81406-59, 81406, 
81405-59, 81405, 81404-59, 81404, 81403-59, 81403, 81402, 81401-59, 81401, 81400, 81321, 81318, 81314, 
81311, 81310, 81299, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81201, 81173, 81121, 81120) 
provided to the enrollee on June 7, 2021. 

 You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the laboratory testing billed and denied are considered redundant to the testing 
allowed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Mutually exclusive edits 
consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In 
some instances, the combination of procedures may be anatomically impossible. Procedures that represent 
overlapping services are considered mutually exclusive. In addition, reporting an initial service and subsequent 
service is considered mutually exclusive. The laboratory testing billed and denied are considered redundant to 
the testing allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT 
code(s): 81406-59, 81406, 81405-59, 81405, 81404-59, 81404, 81403-59, 81403, 81402, 81401-59, 81401, 
81400, 81321, 81318, 81314, 81311, 81310, 81299, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81201, 
81173, 81121, 81120) provided to the enrollee on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain ceramic crown (D2740), provided on June 16, 
2021. 
 
You asked the Plan to pay for a porcelain ceramic crown. You say that the service should be covered. The Plan 
denied your request. The Plan says the service is not covered. 
 
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. 
 
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. Specifically, the service is not listed in the Plan's benefit chart. This 
means the service is not covered. Therefore, we decided that the Plan does not have to pay for a porcelain 
ceramic crown (D2740), provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis treatments provided on April 1, 2021, to April 
29, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dialysis treatments. You say that the enrollee has End-Stage Renal Disease, 
and the treatments are detrimental to the enrollee's health and well-being. 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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the dialysis treatments provided on April 1, 2021, to April 29, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
October 15, 2020, to October 22, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the payment of DRG 853 remains not supported.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with 853. 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 services. Our reviewer says that the services at issue in this case were not supported by 
the medical records. Our physician reviewer found the documentation indicates that the enrollee was 
hospitalized for angiodysplasia of colon with hemorrhage. From the information that was received, 
documentation was inconsistent/unclear regarding a diagnosis of sepsis. Even though severe sepsis is 
documented on medical records, supporting medical record documentation was not found. The enrollee 
presented to the emergency department for confusion. There is no evidence of significant physiologic 
instability. Therefore, the medical record received does not support the condition treated as consistent with a 
systemic infectious process. After review of the submitted medical records, diagnosis was unclear or 
inconsistent regarding diagnosis of metabolic encephalopathy. There was no evidence of change in mental 
status which is beyond baseline, diagnostic work up and treatment to address the diagnosis which may include 
surgical and non-surgical therapies. Although procedure code 0W3P4ZZ control bleeding in GI tract, 
percutaneous endoscopic approach, was reported by the hospital, this appears to be via natural or artificial 
opening endoscopic approach and there is no query or clarification found within the submitted record. The 
review has determined that Principal code A41.9 and Secondary code R65.20, G93.41 and 0W3P4ZZ were 
removed from the claim and diagnosis code K55.21, angiodysplasia of colon with hemorrhage was sequenced 
as principal diagnosis consistent with documentation received.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from October 15, 2020, to October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a tubing extension set (S1015) and infection control supplies 
(S3801) provided on May 10, 2021. 
 
You asked the Plan to pay for a tubing extension set and infection control supplies. You say that these items 
were necessary to safely supply anesthesia. The Plan denied your request. The Plan says these items were not 
billed with valid codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  

We find that CPT codes S1015 and S8301 are not supported in the medical record. Specifically, these codes 
have a status indicator of  Medicare uses another code for reporting of, and payment for these services. 
Based on this information, we decided that Medicare rules for coverage of a tubing extension set and infection 
control supplies have not been met. Therefore, we decided that the Plan does not have to pay for a tubing 
extension set (S1015) and infection control supplies (S3801) provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on April 20, 
2021 and the resin-based composites on April 29, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and resin-based composites. You say that the 
dental work done was vital to the improvement in your rapidly declining health. You say that you thought the 
work would be covered and you do not have the money to pay this bill. The Plan denied your request. The Plan 
says reimbursement has already been issued for a comprehensive oral evaluation and two fillings. 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 
one comprehensive oral evaluation every three years and two amalgam or composite fillings per calendar year. 
The Plan paid for the comprehensive oral evaluation provided on March 31, 2021 and for two fillings provided 
on April 21, 2021, which exhausted your benefits. Therefore, we decided that the Plan does not have to pay for 
the comprehensive oral evaluation provided on April 20, 2021 and the resin-based composites on April 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the radiation therapy services you 
received from March 26, 2021, to April 16, 2021. 
 
You asked the Plan to reduce the cost sharing for the radiation therapy services. You say that these services 
were pre-approved.  You said that you understand you may owe something, but not this much.  You said that 
you had radiation in 2019 and never had to pay this much. The Plan denied your request. The Plan says you 
were charged this coinsurance 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 20% 
coinsurance for therapeutic radiology.  
 
You have been asked to pay 20% coinsurance for the radiation therapy services. The radiation therapy services fall within the therapeutic radiology 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 reduce the cost sharing for 
the radiation therapy services you received from March 26, 2021, to April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on May 21, 2021. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The record shows that the sample for this testing was taken in a 
nursing facility setting, therefore the POS code 81 ? indicating an independent lab setting ? is not appropriate 
for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on May 21, 
2021.