Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the neck, orbit and face 
(70540). 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the requested 
MRI is medically necessary. The Plan denied your request. The Plan says that you do not meet criteria for 
coverage of the MRI. 
 
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 the MRI. Our reviewer says that you 
have a history of thyroid malignancy and radiation therapy.  You have had an extensive workup with no source 
of your symptoms yet discovered. He also have a chronic cough. Our physician reviewer found MRI of the 
neck is a reasonable test in light of your tumor history, extensive workup and persistent symptoms. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the neck, orbit and face (70540).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99205) provided on December 1, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that an authorization is on file for three new patient 
exams for this provider, and this is the first visit for this patient with this provider, group, and specialty. The 
Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services 
were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have 
also determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 an office visit (99205) provided on December 1, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral exam (D0120), intraoral x-rays (D0220, 
D0230), bitewing x-rays (D0272) and cleaning (D1110) provided on January 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that this provider was part of your dental network 
until May 2021. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's 
specified dental network. Out-of-network dental care is not covered by your benefit. Intraoral x-rays are not 
covered by this benefit under any condition. In addition, you state that this provider told you that they were part 
of a specific dental network until May 1, 2021. The network named in your appeal is not the dental network 
provided with your plan. 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. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the dental network specified 
by the Plan. In addition, intraoral x-rays are not listed as a covered service under this benefit. Based on this 
information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, 
we decided that the Plan does not have to pay for the periodic oral exam (D0120), intraoral x-rays (D0220, 
D0230), bitewing x-rays (D0272) and cleaning (D1110) provided on January 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 home health physical therapy. 
 
You asked the Plan to pre-approve 9 home health physical therapy. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 9 home health physical therapy. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the records do not 
show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to 
improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the 
enrollee's level of function and/or prevent deterioration. The enrollee does not appear to require home physical 
therapy as they are able to perform home exercises independently. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9 home health physical therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 9 home health physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 4, 2021. 
You asked the Plan to pay for the dental service. You say that an exception should be made. You say that you 
did not realize that this was negatively affecting the enrollee. The Plan denied your request. The Plan says 
payment cannot be made to providers that have opted out of Medicare. 
 
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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services provided 
on May 16, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the transport was 
related to your COVID-19 diagnosis and the copayment should be waived. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for each ambulance trip.  
 
The file shows that the transportation records do not show any relation to a COVID-9 diagnosis. Therefore, you 
have been asked to pay a $325 copayment for the ambulance transportation. The ambulance transportation 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 
ambulance transportation services provided on May 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided August 21, 2021. 
 You asked the Plan to pay for the electrocardiogram. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed 
and is not eligible for separate payment. 
 
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 93010 
has a bundled relationship with code36556. 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 an electrocardiogram (93010) provided August 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (76641) provided on 
November 16, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered as 
you were not made aware of the copayment beforehand. The Plan denied your request. The Plan says the cost-
sharing applied correctly based on the services provided. 
 
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 $55 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $55 copayment for an ultrasound. Ultrasounds fall 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 an ultrasound (76641) provided on November 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for True Metrix diabetic testing supplies (A4259, A4253, 
A4256) provided March 27, 2020. 
 
You asked the Plan to pay for the True Metrix diabetic testing supplies. You say that the items were medically 
necessary. The Plan denied your request. The Plan says this brand of diabetes supplies is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those 
preferred brands and manufacturers.  
 
We looked at the file and Medicare rules. The records provided give no rationale for why the preferred brand 
would be unsafe or ineffective for the enrollee. Based on this information, we decided that Medicare rules for 
coverage of the True Metrix diabetic testing supplies have not been met. Therefore, we decided that the Plan 
does not have to pay for True Metrix diabetic testing supplies (A4259, A4253, A4256) provided March 27, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 12, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 
provided. 
 
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 $40 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $40 copayment for the specialist office visit. Specialist office visits fall within 
the Physician/Practitioner services, including doctor's office visits 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 a specialist office visit provided on November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second dental extraction (code D7140) and two bone 
replacement grafts for ridge preservation (code D7953) you received on October 1, 2021. 
 
You asked the Plan to pay for the second dental extraction and the two bone replacement grafts. You say that 
the dentist refused to take your card.  You said that the provider ended up billing the Plan for the same two 
extractions that you paid for out-of-pocket, and the provider only got paid for one extractions.  You stated that 
the provider has not reimbursed you for the one extraction paid by the Plan. You also stated that the provider 
never discussed anything about a bone graft with you or whether it would be covered by insurance. The Plan 
denied your request. The Plan says you are only entitled to one dental extraction per year.  The Plan also says 
that the bone replacement grafts are not covered under your supplemental dental benefit. The Plan says that you 
signed a treatment plan at the dentist's office where you acknowledged that the second extraction was not 
covered and that you would be responsible for the two bone replacement grafts.   The Plan also stated that they did issue you direct payment for the one extractions, but apparently you did not 
receive it.  The Plan has reissued the check for this single extraction to you. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a second 
dental extraction (code D7140) and two bone replacement grafts for ridge preservation (code D7953) you 
received on October 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (70450) provided October 18, 2021. 
 You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed 
and is 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 CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 radiology services (70450) provided October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic X-ray (D0330) provided on November 2, 2021. 
 
You asked the Plan to pay for a panoramic X-ray. You say that you do not have the money to pay the charge 
assessed by the provider. The Plan denied your request. The Plan says the service at issue is not a Plan benefit. 
 
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 a 
panoramic X-ray (D0330) provided on November 2, 2021.  
Your complaint about the difficulty of the Plan's appeals process 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 the core build up (D2950) provided on August 3, 2021. 
 
You asked the Plan to pay for the core build up. You say that the services were medically necessary. The Plan 
denied your request. The Plan says core build up is not listed as a covered service. 
 
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 core build up is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up 
(D2950) provided on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have billed these services correctly. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the member's face-to-face service was rendered in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for lab services provided on July 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided on November 4, 2021. 
 
You asked the Plan to waive the copayment for an x-ray. You say that the service provided should be covered 
under your surgery and it should not have a separate copayment. The Plan denied your request. The Plan says 
the proper copayment was applied for this service. 
 
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 $100 
copayment for when X-rays are performed in an outpatient hospital facility. The total amount allowed was 
$95.36 which is less than the $100 copayment amount. Therefore, the copayment amount was $95.36. 
 
  You have been asked to pay a $95.36 copayment for an x-ray. An x-ray 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 an x-ray provided on November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous (D7950) provided by a participating provider on 
September 28, 2021. 
 
You asked the Plan to pay for osseous. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says D7950 is not a covered benefit. 
 
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 osseous 
(D7950) provided by a participating provider on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a filling (D2335), provided on October 4, 2021. 
 
You asked the Plan to pre-approve a filling. You say that you need this service. The Plan denied your request. 
The Plan says you have exhausted the plan benefit for this service. 
 
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, records indicated you have previously received two 
filling during the calendar year. Therefore, we decided that the Plan does not have to pre-approve a filling 
(D2335), provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series x-ray (D0210) provided on November 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that the provider advised the services would be 
covered. You say that you still have $600 left to use. You say that if you had known the services would not be 
covered you would not have gotten them. You also say that you need help with this bill. The Plan denied your 
request. The Plan says the claim processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the comprehensive oral evaluation 
and complete series x-ray are listed as covered, the frequency limits have been exceeded. The record shows that 
the Plan paid for a comprehensive oral evaluation and panoramic x-ray that you received on August 2, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and 
complete series x-ray (D0210) provided on November 2, 2021.