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

 
We decided that the Plan does not have to pay more for prophylaxis (D1110), intraoral imaging (D0220), 
bitewings (D0274), and a periodic oral evaluation (D0120), provided by an out-of-network provider on May 4, 
2022, to May 18, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel like the Plan should pay for this. 
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 prophylaxis (D1110), intraoral imaging 
(D0220), bitewings (D0274), and a periodic oral evaluation (D0120), provided by an out-of-network provider 
on May 4, 2022, to May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing procedures (83789) billed for date of service 
January 27, 2022. 
 
You asked the Plan to pay for validity testing. You say that the validity testing at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the services at issue are included in other billed 
codes. 
 
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 validity testing have not been met. Specifically, we find that the testing described by the billed 
code is considered specimen validity testing which is not separately payable. Therefore, we decided that the 
Plan does not have to pay for validity testing procedures (83789) billed for date of service January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presumptive drug test (80307) provided May 17, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the code denied as a duplicate claim as 
another provider billed the same code on the same date of service. You are sending medical records to prove 
medical necessity. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid 
claim and was correctly denied.  
The Plan must follow Medicare rules. The rules say that only one presumptive service may be billed per 
patient, per DOS, regardless of the provider. Medicare will process the first presumptive service received per 
patient, per DOS. All subsequent claims for a presumptive service for the same patient and same DOS will be 
denied. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 28, 2022 for CPT code 80305 to another provider. Based on this information, 
we decided that the Medicare rules for the laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for presumptive drug test (80307) provided May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on March 31, 2022. 
 
You asked the Plan to pay for code 83789. 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 not covered as billed. 
 
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 the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on March 31, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the beneficiary has 
passed, and you would like the copayments waived. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 $265 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $265 for these 
services. 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 ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller 
harness (E2313), electronic connection (E2311) and a power seat elevation feature (E2300) for the enrollee. 
 
 
 You asked the Plan to pre-approve an expandable controller, expandable controller harness, electronic 
connection and a power seat elevation feature. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's upper limb strength and function are adequate for the 
member to be able to control the power options using their own switches which are included in the allowance 
of these power options. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that a power seat elevation feature is non-covered because it is 
not primarily medical in nature. 
 
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 an expandable controller, expandable 
controller harness and electronic connection. Our reviewer says that an expandable controller, expandable 
controller harness and electronic connection are not considered medically reasonable and necessary in this case. 
The enrollee has 4 out of 5 bilateral upper extremity strength with normal range of motion and is independent 
with eating and grooming thus indicating he has adequate upper extremity strength and function to operate the 
wheelchair's power options with their own switches. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of an expandable controller, expandable controller harness and electronic 
connection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller, expandable controller harness, electronic connection 
and a power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-
approve an expandable controller (E2377), expandable controller harness (E2313), electronic connection 
(E2311) and a power seat elevation feature (E2300) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound debridement provided on October 1, 2021, to October 
22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for wound debridement. You say that authorization should have been obtained by 
the facility or the patient's referring physician. The Plan denied your request. The Plan says in Chapter three on 
pages 39 to 40 of the Plan's 2021 Evidence of Coverage (EOC) 
 
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 wound debridement provided on October 1, 2021, 
to October 22, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit on April 18, 2022, to April 
24, 2022. 
 
You asked the Plan to waive the copayment for urgent care visit. You say that the services should be covered 
because you were very sick and tried to see your PCP but PCP was away. The Plan denied your request. The 
Plan says the cost sharing you are being charged 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 a $50 
copayment for each Medicare-covered urgent care facility visit. This copayment is not waived if you are 
admitted as an inpatient to the hospital within 24 hours for the same condition. Urgently needed services are 
provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate 
medical care. Urgently needed services may be furnished by network providers or by out-of-network providers 
when network providers are temporarily unavailable or inaccessible. There were 2 visits. $50 x 2 = $100. 
Therefore, results in the total cost sharing of $100.  
 
You have been asked to pay a $50 copayment for each urgent care visit. Urgent care visits fall within the 
Urgently needed 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 urgent care 
visit on April 18, 2022, to April 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on March 9, 2022. 
 
You asked the Plan to pay for code 83789. 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 not covered. 
 
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 the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on March 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for infusions provided on April 7, 2022. 
 
You asked the Plan to waive the cost for infusions. You say that you never had to pay a coinsurance before and 
feel you should not have to pay one now. The Plan denied your request. The Plan says you were charged this 
cost sharing 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 $90 
outpatient hospital copayment and 20% coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a $90 outpatient hospital copayment. For Medicare Part B drugs, the allowed 
amount was $434.77 x 20% coinsurance = $86.96 for infusions. You have been asked to pay a total of $176.96 
($86.96 + $90 = $176.96). 
Infusions fall 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 cost for infusions provided on April 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sinus augmentation via a vertical approach (D7952 x 2) 
and the surgical placement of an implant body: endosteal implants (D6010 x 2) provided on May 24, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the sinus 
augmentation via a vertical approach (D7952 x 2) and the surgical placement of an implant body: endosteal 
implants (D6010 x 2) provided on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it is the responsibility of the hospital staff to verify 
eligibility to obtain the proper authorization. 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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on March 10, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy (D3410), a guided tissue regeneration 
(D4266), a retrograde filling (D3430), and an additional intraoral imaging (D0230), provided by an out-of-
network provider on June 13, 2022. 
 
You asked the Plan to pay for an apicoectomy, a guided tissue regeneration, a retrograde filling, and an 
additional intraoral imaging. You say that if you had known this was how much this would cost, you would not 
have had these services provided. The Plan denied your request. The Plan says these services have been 
correctly denied. 
 
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, D3410, D4266, and D3430 are not 
among those covered under this benefit. Two intraoral images were provided on September 13, 2021. Three 
additional intraoral images were provided on June 13, 2022. Therefore, we decided that the Plan does not have 
to pay for an apicoectomy (D3410), a guided tissue regeneration (D4266), a retrograde filling (D3430), and an 
additional intraoral imaging (D0230), provided by an out-of-network provider on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for pain management injections provided on 
March 28, 2022, April 4, 2022, and April 11, 2022. 
 
You asked the Plan to waive the copayment for pain management injections. You say that you were not 
expecting this large copayment for each injection. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 $300 
copayment per visit at an ambulatory surgical center.  
 
You are being charged a total copayment of $843.75 rather than the full total copayment amount of $900 for 
pain management injections. Pain management injections 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 pain management injections 
provided on March 28, 2022, April 4, 2022, and April 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a complete 
series of radiographic images (D0210) provided by a participating provider on May 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that this would be covered. 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 February 6, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and a 
complete series of radiographic images (D0210) provided by a participating provider on May 31, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the thoracic spine 
(72146). 
 
You asked the Plan to pre-approve an MRI of the thoracic spine. You say that the service is medically 
necessary. The Plan denied your request. The Plan says that the service at issue is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the thoracic spine. Our 
reviewer says that the service is medically necessary. Our physician reviewer found with the history of multiple 
compression fractures, osteoporosis and a family history of multiple myeloma the possibility of a thoracic spine 
compression fracture causing the enrollee's symptoms is real. The best way to evaluate the thoracic spine for 
same would be an MRI of the thoracic spine which should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the thoracic spine have been met. Therefore, we decided that the 
Plan has to pre-approve a magnetic resonance imaging (MRI) of the thoracic spine (72146).  
 
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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for non-emergency ambulance services (A0428, A0425) provided on April 
20, 2022. 
 
You asked the Plan to pay for non-emergency ambulance services. You say that the enrollee was transported 
for wound care from the SNF facility, and that ground transportation is a covered benefit per Medicare 
guidelines. The Plan denied your request. The Plan says that the claim has already been paid to the SNF. 
 
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 Plan has failed to provide evidence that the enrollee was in a Part A covered 
SNF stay during the date in question. Therefore, we decided that the Plan has to pay for non-emergency 
ambulance services (A0428, A0425) provided on April 20, 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.