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

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
January 17, 2022. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you should not have another 
copayment for test results given over the phone. 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 $45 
copayment for each specialist visit, including telehealth services.  
 
You have been asked to pay a $45 copayment for the telehealth visit. The telehealth visit falls 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 telehealth visit provided on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided February 16, 2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you thought you were getting a 
regular cleaning. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
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 the 
periodontal maintenance (D4910) provided February 16, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endoscopy performed on March 23, 
2022. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that the procedure should be 
considered preventive due to your family history and should be covered. 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 $250 
copayment for surgery or services performed in a hospital or ambulatory surgical center.  
 
You have been asked to pay a $250 copayment for the endoscopy. The endoscopy 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 an endoscopy performed on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing 
x-rays (D0274) provided on November 18, 2021, by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you called to confirm your allowance amount 
and that your provider was not on the Medicare Exclusion List. You also say that you were given a phone 
number for your dentist to bill out of network. The Plan denied your request. The Plan says dental services that 
you receive out of network are 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 dental services you received out of 
network are not among those covered under this benefit. Additionally, the record shows that the plan 
representative advised the provider was not listed under the Plan's system. Therefore, we decided that the 
Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided 
on November 18, 2021, by the out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on January 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not have the services rendered. The 
Plan denied your request. The Plan says the claim has processed correctly. 
 
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 Plan's dental benefit 
states that if a method of treatment is more costly than what is customarily provided, benefits will be paid on 
the least costly method of treatment, and you will be responsible for the remaining balance.
 
We looked at the file and Medicare rules. In this case, you are responsible for the difference between the 
allowed amounts of the prophylaxis services and the periodontal maintenance based on the Plan's contract. 
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 dental services provided on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic evaluation (D0120), prophylaxis services 
(D1110) and complete intraoral X-ray (D0210) provided on February 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like this claim reprocessed and be 
further reimbursed. The Plan denied your request. The Plan says this claim has denied correctly. 
 
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 dental benefit states This 
benefit states that the periodic evaluation (D0120) and prophylaxis services (D1110) are covered once every 6 
months. The benefit states that intraoral X-rays (D0210) are covered at an 80% coinsurance with an out-of-
network provider. Your cost share will be higher when seeing an out-of-network provider. 
 
We looked at the file and Medicare rules. In this case, the record demonstrates that the periodic evaluation and 
prophylaxis services had previously been covered within 6 months of the February 7 date of service. Therefore, 
the benefit for these dental services had been exhausted at the time the services were rendered on February 7, 
2022. Regarding the intraoral X-rays, the coinsurance has processed correctly. You are being charged the 
coinsurance of $55.37 ($69.22 Medicare allowed amount x 80% coinsurance) in addition to the difference 
between what the out-of-network provider charged and the Medicare allowed amount ($165 - $95.78). 
Therefore, we decided that the Plan does not have to pay for the periodic evaluation (D0120), prophylaxis 
services (D1110) and complete intraoral X-ray (D0210) provided on February 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy with biopsy of 
large bowel (45380) provided on February 24, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that the claim was 
processed with an incorrect CBT (Current Procedural Terminology) code. Furthermore, you requested that the 
claim be billed as a colonoscopy rather than a surgical service. The Plan denied your request. The Plan says the 
cost-share was applied correctly. The claim was billed appropriately as a colonoscopy, however, the procedure 
was diagnostic in nature and was conducted in an ambulatory surgical center.   
 
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 $275 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. This benefit category 
includes diagnostic colonoscopies. 
 
 
 You have been asked to pay a $275 copayment for a diagnostic colonoscopy. Diagnostic colonoscopies fall 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. While the 
service location was an ambulatory surgical center, the actual procedure you received was not a surgical 
procedure and was not billed as such. 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 diagnostic 
colonoscopy with biopsy of large bowel (45380) provided on February 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 2, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not have 
to pay for both ground ambulance trips for the same day. 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 $250 
copayment for each one-way ambulance trip.  
 
You have been asked to pay $237.09, which is less than the $250 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 provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine dental services rendered on September 10, 2021 
to October 4, 2021. 
 
You asked the Plan to pay for these services. You say that financial help would be appreciated. The Plan denied 
your request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for 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 pay for the routine dental services 
rendered on September 10, 2021 to October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from an out-of-network dentist 
on January 25, 2022. 
 
You asked the Plan to pay for the out-of-network dental services. You say that you have been receiving dental 
care from this provider for many years.  You were told that in 2020 and 2021, visits with this dentist were 
covered due to COVID-19. You said that you were not aware that this provider was not in-network. The Plan 
denied your request. The Plan says out-of-network dental services are not covered. 
 
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. Your Plan's dental benefit 
does not cover dental services provided by an out-of-network dentist. 
 
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 dental 
services you received from an out-of-network dentist on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - two surfaces, anterior (D2331) 
provided March 18, 2022. 
 
You asked the Plan to pay for the filling. You say that you were not aware that fillings were not covered in 
your preventative plan. The Plan denied your request. The Plan says this service is not covered under your 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 the resin-
based composite - two surfaces, anterior (D2331) provided March 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right knee joint replacement surgery to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve right knee joint replacement surgery to be provided by an OON provider. 
You say that the services are necessary. The Plan denied your request. The Plan says there are in-network 
providers that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
right knee joint replacement surgery to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing to measure the level of PSA in 
your blood (84153) provided on January 20, 2022. 
 
You asked the Plan to waive the copayment for lab services. You say that the Plans public website indicates 
that lab services have a $0 copayment. You say you would like your cost-share for the lab tests to be $0. The 
Plan denied your request. The Plan says review of the Summary of Benefits, the Annual Notice of Change, and 
the 2022 EOC (all available on the Plans public website) confirms that lab services have a copayment between 
$0 and $10 per visit. Blood services, which have a $0 copayment, are under a separate benefit from the lab 
testing services you received. Blood services includes storage and administration of blood, not blood draws for 
laboratory testing.  
Furthermore, the Plan reviewed the claim and verified with the provider that the lab services were not 
conducted as part of an Annual Physical Exam, Annual Wellness Visit, or Welcome to Medicare preventive 
visit. 
 
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 $10 
copayment, per visit, for laboratory and non-radiological diagnostic tests.  
 
You have been asked to pay a $10 copayment for lab services. Lab services fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. You received the services at issue 
separate from an Annual Physical Exam, Annual Wellness Visit, or Welcome to Medicare preventive visit. 
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 lab testing to measure the level of PSA present in your 
blood (84153) provided on January 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of head or brain 
(70450). 
 
You asked the Plan to pre-approve a CT scan. You say that the service was medically necessary. The Plan 
denied your request. The Plan says despite multiple attempts, no medical records were obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a computed tomography (CT) scan of 
head or brain (70450). have been met. Specifically, no medical records were submitted with this appeal to 
determine the medical necessity of this service.. Therefore, we decided that the Plan does not have to pre-
approve a computed tomography (CT) scan of head or brain (70450).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; third and any additional level(s) (CPT code 64495). 
 
You asked the Plan to pre-approve the service. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollees request is not medically necessary because their records do not show a 
unique circumstance and with sufficient documentation of medical necessity on appeal to approve the third 
level. 
 
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 service. Our physician reviewer 
found the request exceeds the utilization criteria of the LCD, only 2 levels bilaterally would be normally 
allowed at one session and there is no special circumstance that requires more than two (2) levels to be done at 
one session. The request for a third level is not medically reasonable or 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 the service have not been met. 
 Therefore, we decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; third and any additional level(s) (CPT code 64495).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from June 1, 2021, to December 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told that this provider was in-network. 
The Plan denied your request. The Plan says this provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for services provided directly by a physician or practitioner who has opted out of the program except in cases 
involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-
urgent, non-emergent situation by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for dental services you received from June 1, 2021, to December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical x-ray (code D0220) and the limited 
oral exam (code D0140) you received on January 31, 2022. 
 
You asked the Plan to pay for the intraoral periapical x-ray (code D0220) and the limited oral exam (code 
D0140). You say that these services were needed due to a gum issue related to your diabetes, so this should be 
covered under your medical benefits. The Plan denied your request. The Plan says these services are not 
covered. 
 
Medicare generally does not cover dental services. This includes services related to the gums, regardless of any 
underlying medical condition. This means that there is no coverage for these services under your medical 
benefits. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 
coverage rules apply in this case. The Plan's dental benefit includes coverage only for the specific dental 
procedures and codes listed in your dental benefits chart. Neither of the services in dispute in this appeal are listed in this chart. 
 
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 the 
intraoral periapical x-ray (code D0220) and the limited oral exam (code D0140) you received on January 31, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Prednisone. 
 
You asked the Plan to pre-approve Prednisone. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says the drug is self administered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Prednisone.