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

 
We decided that the Plan does not have to pay for the endodontic therapy (D3320) and surgical procedure for 
isolation of tooth with rubber dam (D3910) provided on April 5, 2022. 
 
You asked the Plan to pay for the endodontic therapy and surgical procedure. You say that you believe services 
provided by general dentists are covered under your dental benefit. The Plan denied your request. The Plan 
says these services are not covered expenses under your dental plan. The Plan also says that you did not contact 
the Plan prior to the date of service to verify benefits and provider eligibility. 
 
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 
endodontic therapy (D3320) and surgical procedure for isolation of tooth with rubber dam (D3910) provided on 
April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) and periapical x-ray 
(D0220) on May 9, 2022. 
 
You asked the Plan to pay for periodontal maintenance and periapical x-ray. You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says these services aren't 
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. 
 
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 
periodontal maintenance (D4910) and periapical x-ray (D0220) on May 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 27, 2021, billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. 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. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 27, 2021, billed with codes 81206 and 81292.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on March 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to find a different dentist. You say that 
this should be covered. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 17, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on July 23, 2021. 
 
You asked the Plan to pay for code 80050. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmology office visit provided on 
January 12, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you dont understand where the $35 
copayment came from. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $35 
copayment for each Medicare-covered visit. 
 
You have been asked to pay $35 copayment for ophthalmology office visit. Office visits fall within the Vision 
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 ophthalmology office visit 
provided on January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on March 8, 2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you currently receive treatments 4 
times per year, instead of regular semi-annual cleanings. You also say you feel you should be entitled to at least 
the allowed for normal cleanings twice per year. The Plan denied your request. The Plan says this service 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 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 on March 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 28, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee is being seen for pharmacologic 
therapy and needs to have laboratory work done monthly. 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 laboratory services provided on March 28, 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 the comprehensive oral evaluation (D0150) provided on 
February 9, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you could not reasonably have 
waited 36 months to get dental work that was already scheduled. The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 8, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on January 28, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay for chiropractic services. You say that the provider and referring providers are 
participating providers with Medicare. The Plan denied your request. The Plan says the enrollee went to an out-
of-network provider and services were not 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 chiropractic services provided on January 28, 
2022, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on December 27, 2021. 
 
You asked the Plan to pay for the dental services. You say that you are allowed two exams a year. You say that 
this should be covered. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 12, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on April 13, 2021. 
 
You asked the Plan to pay for the testing services. You say that you enable physicians to deliver personalized 
cancer care. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 looked at the file and the rules. We find that the panel was not billed with a single code as required. Based 
on this information, we decided that Medicare rules for coverage of the testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the gene panel testing provided on April 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the $57.55 copayment for an ultrasound performed on March 
11, 2022. 
 
You asked the Plan to reduce the $57.55 copayment for an ultrasound. You say that should only be responsible 
for a $20 copayment for an ultrasound. The Plan denied your request. The Plan says the copayment has been 
applied 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 $60 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $57.55 copayment for an ultrasound. An ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. Your contract with the Plan clearly 
says that you must pay a $60 copayment for an ultrasound. However, you have only been asked to pay $57.55, 
which is less than $60.00 copayment amount. 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 $57.55 copayment for an 
ultrasound performed on March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pathology and laboratory procedure provided on March 10, 
2022, provided on March 10, 2022, by an OON provider. 
 
You asked the Plan to pay for a pathology and laboratory procedure. You say that the doctor's office failed to 
send in a preauthorization form for approval. The Plan denied your request. The Plan says the out-of-network 
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 a pathology and laboratory procedure provided on 
March 10, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 22, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit at issue in this appeal. The Plan did not pre-approve the 
office visit at issue. We found no exception that would require the Plan to pay for these office visit. Therefore, 
we decided that the Plan does not have to pay for office visit provided on March 22, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophageal motility study provided on 
March 1, 2022. 
 
You asked the Plan to waive the copayment for an esophageal motility study. You say that this was a simple 30 
minute swallowing test conducted in a medical office setting. You say that you were not in an outpatient setting 
and was not give a hospital bracelet for the procedure. The Plan denied your request. The Plan says you have 
been charged the correct copayment 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 $330 
copayment per date of service billed by an outpatient hospital or hospital-owned facility.  
 
 
 You have been asked to pay a $330 copayment for an esophageal motility study. The esophageal motility study 
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 
esophageal motility study provided on March 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $13.79 coinsurance for a shoulder orthosis received on 
March 18, 2022. 
 
You asked the Plan to waive the $13.79 coinsurance for a shoulder orthosis. You say that you should not be 
responsible for this coinsurance because it was medically necessary due to a fall. The Plan denied your request. 
The Plan says the coinsurance has been applied 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 20% 
coinsurance for Prosthetic Devices and Related Supplies.  
 
You have been asked to pay a $13.79 coinsurance for a shoulder orthosis. A shoulder orthosis falls within the 
Prosthetic Devices and Related Supplies benefit category. The Plans allowance was $68.95; $68.95 x 20% = 
$13.79. 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 $13.79 coinsurance for a shoulder orthosis received on March 
18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gloves and tubing extension provided on March 
10, 2022. 
 
You asked the Plan to pay for the services provided. You say that the records indicate the services were an 
emergency. The Plan denied your request. The Plan says the services are not eligible for 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. 
 We find that CPT S1015 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT code 
S1015 is not valid for Medicare purposes. We also find that CPT A4930 is a packaged item. This service is 
packed into payment for other services. Based on this information, we decided that Medicare rules for coverage 
of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
sterile gloves and tubing extension provided on March 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmic ultrasound provided on 
March 17, 2022. 
 
You asked the Plan to waive the copayment for an ophthalmic ultrasound. You say that you shouldn't be 
charged extra for the ultrasound. The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $100 
copayment per day for a Medicare-covered ultrasound.  
 
You have been asked to pay $13.16 which is less than the standard $100 copayment for an ophthalmic 
ultrasound. Ophthalmic 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 ophthalmic ultrasound 
provided on March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on March 16, 2022. 
 
You asked the Plan to pay for the gingival irrigation. You say that you are proactive in all your dental care at 
home and the staff at the dentist's office said they would discuss any fees with you, which they did not do. The 
Plan denied your request. The Plan says this service is not covered under your 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 
gingival irrigation (D4921) provided on March 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have waive the $103.58 copayment for x-rays taken on April 5, 2022. 
 
You asked the Plan waive the $103.58 copayment for x-rays taken on April 5, 2022. You say that the x-ray was 
medically necessary, and you should not be responsible for this copayment. The Plan denied your request. The 
Plan says the copayment has been applied 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 pay a $110 for 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
 
 
 
 
 You have been asked to pay a $103.58 for x-rays taken on April 5, 2022. X-rays fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. Your contract with the Plan clearly 
says that you must pay a $110 copayment for x-rays taken outside a physicians office. However, you have 
only been asked to pay $103.58, which is less than the copayment amount. 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 
waive the $103.58 copayment for x-rays taken on April 5, 2022.