Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the partial or complete reconstruction of the 
mandible or maxilla with endosteal implant (21249) provided September 20, 2022. 
 
You asked the Plan to reimburse you for the dental surgery. You say that you paid $53,900 out of pocket and 
was only paid $1,962.62. The Plan denied your request. The Plan says this cost sharing was charged correctly 
as the Plan's share was fully reimbursed. 
 
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 10% 
coinsurance of the approved amount for Dental services.  
 
You have been asked to reimburse you for the dental surgery. The records provided did not include 
documentation of any payments you have made. The Plan paid the full Medicare allowed amount. This 
item/service falls within the Dental services benefit category. This means that you have been paid 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 reimburse you for the 
partial or complete reconstruction of the mandible or maxilla with endosteal implant (21249) provided 
September 20, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for transcutaneous electrical nerve stimulator (TENS) unit leads provided 
on August 7, 2022. 
 
You asked the Plan to pay for TENS supplies. You say that this claim has been incorrectly denied. The Plan 
denied your request. The Plan says that the treating practitioner did not order this. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. 
 We looked at the file and Medicare rules. The records show a written order for electrical stimulator supplies 
from a treating practitioner. The case file included medical records showing that the practitioner who signed the 
order was treating the enrollee and that their plan's for treatment included the use of an electrical 
stimulator. The plan has not substantiated their denial reason. Based on this information, we decided that 
Medicare rules for coverage of TENS supplies have been met. Therefore, we decided that the Plan has to pay 
for transcutaneous electrical nerve stimulator (TENS) unit leads provided on August 7, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
October 30, 2022. 
 
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 this claim is a duplicate. 
 
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 additional units of CPT codes 71045, 74177, and 70450 are not supported in the medical record. 
Specifically, the record does not contain evidence that these services were provided multiple times on this date. 
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 additional imaging services provided to the 
enrollee on October 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service October 8, 
2022 to November 4, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
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 code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service October 8, 2022 to November 4, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the prostate specific antigen (PSA) (84154) provided July 13, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that you do not know for certain, but you are 
guessing that this claim was denied because the test was not ordered by your primary care physician of record. 
The Plan denied your request. The Plan says that the service is not covered by the Plan. 
 
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. Neither the Plan's reason to deny or any records was not provided. The case file 
provided was insufficient and the Plan has not substantiated their reason to deny. Therefore, we decided that 
the Plan has to pay for the prostate specific antigen (PSA) (84154) provided July 13, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 16, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says per Medicare, the 
provider must attempt to consult the attending or primary care physician about the services furnished and 
document the consent or declination date to consultations and the date of consultations in the patients medical 
record. If consultation with the attending or primary care physician is unsuccessful, document the patients 
medical chart with the date and manner of notification to the physician. There was no documented contact with 
the attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the physical therapy evaluation (97161) and therapeutic exercises 
(97110) provided on July 15, 2021. 
 
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 that these services are not a covered benefit 
when provided by a chiropractor. 
 
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. Specifically, the services at issue in this case were denied by the Plan as they 
were provided by a chiropractor. However, per review of the claim and the medical records submitted, the 
provider who rendered the services in this case is a physical therapist. The Plan has not substantiated their 
denial; therefore, we must find in your favor. Therefore, we decided that the Plan has to pay for the physical 
therapy evaluation (97161) and therapeutic exercises (97110) provided on July 15, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 19, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that this claim should be covered. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 19, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve a foot insert. You say that you would like reconsideration because the 
requested foot insert is medically necessary. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transfer bench for tub or toilet with or without 
commode opening. 
 
You asked the Plan to pre-approve a transfer bench. You say that you would like reconsideration because the 
requested transfer bench is medically necessary. The Plan denied your request. The Plan says this item is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a transfer bench for tub or toilet with or 
without commode opening.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0431 and A0436) provided on July 
14, 2022 
 
You asked the Plan to pay for the ambulance services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
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 ambulance services have not been met. Review of the file 
shows that the services were billed with a GZ modifier. The rules say that claim lines with GZ modifier are automatically denied as non-covered services. Therefore, we decided that the Plan does not have to pay for the 
ambulance services (A0431 and A0436) provided on July 14, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 17, 2022. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says that per 
Medicare, the provider must attempt to consult the attending or primary care physician about the services 
furnished and document the consent or declination date to consultations and the date of consultations in the 
patients medical record. If consultation with the attending or primary care physician is unsuccessful, 
document the patients medical chart with the date and manner of notification to the physician. There was no 
documented contact with the attending/primary care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on May 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on August 05, 2022, to August 10, 
2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
August 05, 2022, to August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 3, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says services from 
non-participating providers are not covered under open access unless preauthorized. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on August 03, 2022, to 
August 10, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that this should be covered. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for injections. This item/service 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. You have been asked to pay $1,271.72 ($635.86 x 2 visits) coinsurance for the injections. 
Therefore, we decided that the Plan does not have to waive the coinsurance for injections provided on August 
03, 2022, to August 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 30, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on August 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, an electrocardiogram, and laboratory services 
provided on August 23, 2022. 
 
You asked the Plan to pay for an office visit, an electrocardiogram, and laboratory services. You say that you 
are appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit, an 
electrocardiogram, and laboratory services provided on August 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out of network physical therapy visits 
provided on August 17, 2022, to August 19, 2022. 
 
You asked the Plan to waive the coinsurance for out of network physical therapy visits. You say that you 
should only be charged the in network rate. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for outpatient rehabilitation services. 
 
You have been asked to pay 40% coinsurance for out of network physical therapy visits. This item/service falls 
within the outpatient rehabilitation 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 coinsurance 
for out of network physical therapy visits provided on August 17, 2022, to August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 15, 2022. 
 
You asked the Plan to pay for office visit. You say that you say that you should not be paying for this visit, it 
should be covered under your insurance. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220) 
provided on March 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service that was provided should be covered 
under the insurance allowance. 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. This benefit includes the 
requested intraoral - periapical first radiographic image (D0220) but is limited to one set of bitewing x-rays (up 
to four views) every year, or up to six periapical films every year (not both). 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. You 
previously received covered D0274 on January 20, 2022, and D0220 provided on March 18, 2022. Although 
these are two different services, they fall within the same category in your Evidence of Coverage and are 
subject to the same frequency limitations. Therefore, these benefits were exhausted as of  January 20, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral - periapical first radiographic image 
(D0220) provided on March 18, 2022.