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

 
We decided that the Plan does not have to pay for procedure codes 93005 and 93041 provided on September 
22, 2022. 
 
You asked the Plan to pay for procedure codes 93005 and 93041. 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 must report services correctly. 
 
We find that CPT codes 93005 and 93041 are packaged services due to being billed on the same claim as code 99285, which has a status indicator of V. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 93005 and 93041 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 93005 and 93041 provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 6, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that medically necessary care was 
provided in good faith. The Plan denied your request. The Plan says the services were not authorized. 
 
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 subsequent nursing facility care provided on June 
6, 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 a comprehensive periodontal evaluation (D0180) provided 
on September 21, 2022. 
 
You asked the Plan to pay for the dental service. You say that the evaluation is a normal procedure, and the 
Plan should pay for the service. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the comprehensive periodontal evaluation is not covered by the Plan. 
 
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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite (D2140) for tooth #5 
provided on November 8, 2022. 
 
You asked the Plan to pay more for the dental service. You say that the filling was not cheaper, and you only 
expected to pay half. The Plan denied your request. The Plan says you are responsible for the difference in 
allowed amount. 
 
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. The original allowed amount 
for the resin-based composite (D2391) was $161. The total allowed amount for the approved resin-based 
composite (D2140) was $124. The difference in the allowed amount was $37 ($161 billed - $124 approved). 
 
  You have been asked to pay the difference between the allowed amount of the less expensive alternate 
procedure. 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 the resin-based composite (D2140) for tooth 
#5 provided on November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral photographic images (D0350) and anesthesia 
(D9211) provided on October 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are asking for a review of your case. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because the 2D oral 
photographic images and anesthesia are not covered by the Plan. 
 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 2D 
oral photographic images (D0350) and anesthesia (D9211) provided on October 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the podiatry office visits provided on 
August 3, 2022, and October 12, 2022. 
 
You asked the Plan to waive the deductible for podiatry office visits. You say that you already paid your $35 
copayments. 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. Your 
contract with the Plan says that there is a $750 deductible which applies to a podiatry office visit. The Plan 
contract also says that enrollees must pay a $35 copayment for each podiatry office visit after the deductible 
has been met.  
 
The item or services you asked the Plan to waive the deductible for falls within the podiatry office visit benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to a podiatry office visit. This cost sharing is a contractual obligation that had not 
been met at the time podiatry office visits were received on August 3, 2022, and October 12, 2022. Therefore, 
we decided that the Plan does not have to waive the deductible for the podiatry office visits provided on August 
3, 2022, and October 12, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from October 20, 2021, to 
November 6, 2021. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that they were unable to make a 
determination within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the inpatient hospital services provided from October 20, 2021, to November 6, 2021, based on 
Medicare criteria. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided 
from October 20, 2021, to November 6, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says the dental services were received from an out-of-network provider and are not 
covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services provided on December 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 16, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was not covered under hospice at 
the time service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
   
The enrollee ended Medicare Hospice benefits on June 12, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on June 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the pneumatic compression devices 
provided on June 8, 2022. 
 
You asked the Plan to reduce the coinsurance for the pneumatic compression devices. You say that you were 
quoted a lower amount in an estimate by the company providing the equipment. 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 in-network DME. 
 
You have been asked to pay 20% of the allowed amount for each pneumatic compression device. These 
items/services fall within the durable medical equipment benefit category. 
 
 
 
 Item Allowed Amount 20% Coinsurance 
 E0656 $550.00 $110.00 
E0667 $286.19 $57.24 
E0652 $4,686.11 $937.22 
Total $1,104.46 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the coinsurance for the pneumatic compression devices provided on June 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says dental services from an out-of-network 
provider are not covered by your supplemental 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. 
 
 
  You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cochlear implant surgery (L8614, 69930) to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve cochlear implant 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 
cochlear implant surgery (L8614, 69930) to be provided by an out-of-network (OON) provider.
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) (82728, 83540, 83550, and 86704) provided on June 13, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. 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) (82728, 83540, 
83550, and 86704) provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0230), 2D oral 
photographic images (D0350), and a cone beam (D0367) provided on October 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that the x-rays should be covered. The Plan denied 
your request. The Plan says your benefit for the intraoral radiographic images has already been exhausted. 
Also, the denial of payment for the 2D oral photographic images and the cone beam is correct, because they are 
not covered by the 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the intraoral radiographic images was exhausted on date of service October 10, 2022. 
The 2D oral photographic images and the cone beam are not covered under the Plan's dental benefit. Therefore, 
we decided that the Plan does not have to pay for the intraoral radiographic images (D0230), 2D oral 
photographic images (D0350), and a cone beam (D0367) provided on October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-ray, cleaning, 
fillings, and maxillary partial denture (D5214, D5213, D0210, D0150, D2332, D2335, D1110) provided on 
July 19, 2021, to April 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as the claim was not 
filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the dental services was not filed until November 28, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation, intraoral x-ray, cleaning, 
fillings, and maxillary partial denture (D5214, D5213, D0210, D0150, D2332, D2335, D1110) provided on 
July 19, 2021, to April 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Respiratory PCR Panel (87798) provided November 3, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that your lab performed all the tests that were 
ordered by the referring physician. Please review and reprocess the above claim following the CMS guidance. 
The Plan denied your request. The Plan says this procedure is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for the Respiratory PCR Panel (87798) provided November 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80053, 81000, 85025, 86769) provided on 
February 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim was submitted correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
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 sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (80053, 81000, 85025, 86769) provided on February 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray services performed by an in-
network provider on September 29, 2022. 
 
You asked the Plan to waive the copayment for the x-ray services. You say that you were not told that there 
was a cost share for this service. 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 a $50 
copayment for in-network x-rays that are performed in a physician's office or an independent diagnostic testing 
facility (IDTF). 
 
You have been asked to pay a $50 copayment for the x-ray services. This item/service 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 the x-ray services performed by an in-network provider on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99202) and the non-covered 
services (A9270) provided from August 29, 2022, through October 18, 2022. 
 
You asked the Plan to issue reimbursement 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. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue reimbursement for the office visit (99202) and the non-covered services 
(A9270) provided from August 29, 2022, through October 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate (38220). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 bone marrow aspirate. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the available records do not support the need for bone marrow aspirate. There is 
no clinical justification provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (38220).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99223, 32653, 32650, and 31622 provided 
on June 7, 2022. 
 
You asked the Plan to pay for procedure codes 99223, 32653, 32650, and 31622. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says payment is 
included in the global surgery payment. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for services related to the surgery when furnished by the physician who 
performs the surgery. 
 
We looked at the file and Medicare rules. Payment for procedure code 99223 is included in the global surgery 
payment for procedure code 32820 provided on May 24, 2022. Payment for procedure codes 32653, 32650, 
and 31622 are included in the global surgery payment for procedure code 32650 provided on May 24, 2022. 
Separate payment cannot be made for procedure codes 99223, 32653, 32650, and 31622. Therefore, we 
decided that the Plan does not have to pay for procedure codes 99223, 32653, 32650, and 31622 provided on 
June 7, 2022.