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

 
We decided that the Plan does not have to pay for the removal of a support implant (20680) rendered by the 
out-of-network (OON) provider on June 1, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the removal of a support implant (20680) rendered by the out-of-network (OON) 
provider on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation-diagnostic service provided by a dentist or 
physician other than the requesting dentist or physician (D9310) provided on November 15, 2021. 
 
You asked the Plan to pay for dental code D9310. 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. 
 
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, dental code D9310 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for a consultation-
diagnostic service provided by a dentist or physician other than the requesting dentist or physician (D9310) 
provided on November 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visits provided on January 26, 
2021 to November 3, 2021 (38 visits total). 
 You asked the Plan to waive the copayment for the telehealth visits. You say that this service should have a $0 
copayment. The Plan denied your request. The Plan says the copayment amount charged for the telehealth 
visits 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 a $40 
copayment for telehealth visits.  
 
You have been asked to pay a total of $1,520 for 38 telehealth visits ($40 x 38). Telehealth visits falls within 
the Outpatient Mental Health Care 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 
telehealth visits provided on January 26, 2021 to November 3, 2021 (38 visits total).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified periodontal procedure (code D4999) you 
received on October 28, 2021. 
 
You asked the Plan to pay for the unspecified periodontal procedure. You say that you believe the Plan should 
have paid more towards this bill. The Plan denied your request. The Plan says the services billed with code 
D4999 are not covered under your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan contract says that 
only those dental services explicitly listed in your Benefits Chart are covered.  Dental code D4999 is not listed 
in the chart as a covered dental service. Therefore, we decided that the Plan does not have to pay for the 
unspecified periodontal procedure (code D4999) you received on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive dental exam (code D0150) you received 
on December 13, 2021. 
 
You asked the Plan to pay for the comprehensive dental exam. You say that you were told that you would not 
be charged a dental exam fee when you selected a new dentist. The Plan denied your request. The Plan says 
you are only entitled to coverage for one oral exam every year.  You already received a covered oral exam on 
May 25, 2021, so you were not eligible for coverage for the oral exam you received on December 13, 2021. 
 
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 
comprehensive dental exam (code D0150) you received on December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on November 12, 2021, 
rendered by a provider who has opted out of Medicare. 
 
You asked the Plan to pay for the dental services. You say that you would like to be reimbursed for these 
services. The Plan denied your request. The Plan says providers who have opted out of Medicare are not 
eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or 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 the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services provided on November 12, 2021, rendered by a provider who has opted out of Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on November 22, 2021, by a 
provider who has opted out of Medicare. 
 
You asked the Plan to pay for the dental services. You say that you believe you should be reimbursed for the 
dental care. The Plan denied your request. The Plan says payment cannot be made to a provider who 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 items or 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 the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental 
services provided on November 22, 2021, by a provider who has opted out of Medicare.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a Radiologic examination, transportation and set-up of 
portable X-ray equipment provided on September 16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for  a Radiologic examination, transportation and set-up of portable X-ray 
equipment. You say that you would like to appeal the denial of the claim. The Plan denied your request. The 
Plan says the provider is out-of-network and authorization was not obtained prior to the services being 
rendered. 
 
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 Radiologic examination, transportation and set-
up of portable X-ray equipment provided on September 16, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on November 18, 
2021. 
 
You asked the Plan to waive the deductible for an office visit. You say that you were told by the insurance 
company and provider that it was in-network and 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. Your 
contract with the Plan says that there is a $750 deductible which applies to an out-of-network office visit.  
 
The record shows this claim was approved, and you have a cost sharing amount. The office visit you asked the 
Plan to waive the deductible for falls within the Physician/Practitioner Services, Including Doctors Office 
Visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
a $750 deductible which applies to an out-of-network office visit. This cost sharing is a contractual obligation 
that had not been met at the time an office visit was received on November 18, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for an office visit provided on November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the shoe inserts are 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 (L3000).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the measurement of post-voiding residual 
urine and/or bladder capacity by ultrasound (51798) provided on November 19, 2021. 
 
You asked the Plan to waive the copayment for the measurement of post-voiding residual urine and/or bladder 
capacity by ultrasound. You say that the total bill for services came to $320, and of this amount, the Plan 
refused to pay $10.42. You also say that it is your understanding that this procedure is standard and part of the 
treatment you were seeking. The Plan denied your request. The Plan says you were 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 $20 
copayment for Medicare-covered non-radiological diagnostic services.  
 You have been asked to pay $10.42, which is less than the $20 copayment for the measurement of post-voiding 
residual urine and/or bladder capacity by ultrasound. The measurement of post-voiding residual urine and/or 
bladder capacity by ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 
diagnostic 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 the measurement of 
post-voiding residual urine and/or bladder capacity by ultrasound (51798) provided on November 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
July 19, 2021, to January 28, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you would of went 
home instead of being transferred and being charged for a new stay. The Plan denied your request. The Plan 
says the copayment was assessed correctly since the enrollee was transferred to a different type of hospital. 
Also, during the dates of services the enrollee met their annual out-of-pocket maximum. Therefore, the proper 
copayment was applied for this service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $280 
copayment for each day for days 1 to 6 for Medicare-covered hospital care and $0 copayment for additional Medicare-covered days. The total amount chargeable for 6 or more days in an inpatient stay is $1,680 ($280 
copayment per day x 6 days). The total copayment amount charged was $773.24 which is less than the 
copayment amount of $1,680. 
 
You have been asked to pay a $773.24 copayment for the inpatient hospital stay. The inpatient hospital stay 
falls within the Inpatient Hospital Care 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 inpatient hospital stay provided from July 19, 2021, to January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789-59) provided on April 6, 2021. 
 
You asked the Plan to pay for code 83789-59. You say that the medical records support the use of modifier 59 
with code 83789 provided on April 6, 2021. The Plan denied your request. The Plan says the medical records 
do not support the use of modifier 59 with code 83789 provided on April 6, 2021. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   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 pay for code 83789-59. Our reviewer says that the medical records do not support the use of modifier 59 with code 83789 provided on April 6, 2021. Our physician reviewer found the enrollee is with opioid treatment prescribed for chronic pain. Drug testing was 
performed. The medical records do not support the use of modifier 59 with code 83789 provided on April 6, 
2021. The 59 modifier appears to not be supported in this instance as the code is included in the G0480 CPT 
code and would not be appropriate to additionally and separately code for 59 modifier as the service for drug 
testing was not distinct or independent from the other services performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 83789-59 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Mass spectrometry and tandem mass spectrometry (83789-59) provided on April 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve the additional home health physical therapy visits.. You say that you would 
like reconsideration because the requested home health visits are medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet Medicare criteria for coverage. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional home health physical 
therapy visits. Our reviewer says that the documentation doesnt support that the member requires additional 
skilled rehab services to provide treatment that is medically necessary. The member does not require additional 
skilled rehab services to effectively provide treatment, care, and/or services in order to improve the members 
condition, perform a maintenance program to maintain the members condition and/or prevent deterioration. 
Our physician reviewer found the member has been medically stable without any recent exacerbations of 
chronic medical problems or hospitalizations.  The requested home health services are not medically 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 additional home health physical therapy visits. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 16 additional home health physical therapy 
visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that during a prior visit to a hospital the 
out-of-network provider was highly recommended, and you would like to receive care from them. The Plan 
denied your request. The Plan says a list of in-network providers that provide the same quality of service was 
given to the enrollee. Each one of the in-network providers are accepting new patients so there is no urgent or 
emergent reason for the enrollee to see an out-of-network provider for the service requested. 
 
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 
a specialist office visit to be provided 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 crown (D2740), and core build up (D2950) provided on 
December 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were under the impression that crowns were 
covered at 30%. you say that half of your crown came off. You also say that you had no time to get anything 
preapproved. The Plan denied your request. The Plan says the claim denied correctly 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the crown and core build up are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2740), and core build up (D2950) provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 8, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denial. The Plan denied your 
request. The Plan says the services were provided out-of-network and 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 the office visit provided on November 8, 2021, by 
an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the requested services. You say that you are not fully recovered with your 
oxygen level. The Plan denied your request. The Plan says you do not require skilled nursing services to 
maintain your current condition. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that you were admitted to the hospital for pneumonia with respiratory failure. You were 
discharged home with 6 home health skilled nursing visits. You have remained medically stable and have been 
instructed on medication management and disease monitoring. You do not require additional skilled nursing 
services to effectively provide treatment to improve your condition or perform a maintenance program to 
maintain your condition or prevent deterioration. You have been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. Therefore, the requested home health services 
are not medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing services.