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

 
We decided that the Plan does not have to pay for prophylaxis (D1110), and bitewings (D0274) provided by a 
participating provider on July 9, 2021, to January 12, 2022. 
 
You asked the Plan to pay for prophylaxis and bitewings. You say that you were only one day early for the 
time limit. You say that the office schedule this visit, and you should not be penalized for that. The Plan denied 
your request. The Plan says the benefit limit for D1110 and D0274 has already been met and exhausted. 
 
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. 
 
We looked at the file and Medicare rules. Due to the benefit limit still being exhausted at the time of these 
services, these services have been correctly denied. Based on this information, we decided that the Plan's rules 
for coverage of prophylaxis and bitewings have not been met. Therefore, we decided that the Plan does not have 
to pay for prophylaxis (D1110), and bitewings (D0274) provided by a participating provider on July 9, 2021, to January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81292) provided on June 4, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (81206, 81292) provided on June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a breast prosthesis and a breast prosthesis 
mastectomy bra provided on November 29, 2021. 
 
You asked the Plan to waive the coinsurance for a breast prosthesis and a breast prosthesis mastectomy bra. 
You say that you spoke to the owner of the facility and were informed that you will not be billed, and you feel 
the facility should be responsible for this bill. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 
 You have been asked to pay $84.15 in coinsurance, which is 20% of the allowed amount for a breast prosthesis 
and a breast prosthesis mastectomy bra. A breast prosthesis and a breast prosthesis mastectomy bra fall within 
the durable medical equipment (DME) and related 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 coinsurance for a breast prosthesis and a breast prosthesis mastectomy bra provided on November 
29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extensive oral evaluation (D0160), surgical extraction 
(D7250), and sedation (D9223) provided by an opt-out provider on November 19, 2021. 
 
You asked the Plan to pay for dental services. You say that your wife needed this dental work done. The Plan 
denied your request. The Plan says the rendering dentist 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 until September 7, 2023. Therefore, we decided that the Plan does not 
have to pay for an extensive oral evaluation (D0160), surgical extraction (D7250), and sedation (D9223) 
provided by an opt-out provider on November 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold packs therapy (97010) provided on January 26, 2022. 
 
You asked the Plan to pay for hot or cold packs therapy. You say that this claim was denied due to no 
authorization, however these services were pre-approved by the Plan. The Plan denied your request. The Plan 
says they have agreed to pay for the therapy services; however, 97010 remains denied as the payment for this 
service is always bundled into the payment for another service. 
 
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 code 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
hot or cold packs therapy (97010) provided on January 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Subsequent Nursing Facility Care services provided on May 
31, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Subsequent Nursing Facility Care services. You say that that it isn't your 
responsibility to obtain prior authorization. The Plan denied your request. The Plan says the provider is out-of-
network and it was determined these services were not urgent or emergent. 
 
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 services 
provided on May 31, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care provided on January 7, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the observation care. You say that it was medically necessary to treat the enrollee 
and the claim should be covered. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 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 observation care provided on January 7, 2022, 
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation provided on January 11, 2022. 
 
You asked the Plan to pay for the limited oral evaluation. You say that this was due to a direct trauma that 
caused the crown to dislodge, and you visited the dentist to determine if a new crown was required. You say 
that this charge should be covered as part of the procedure to determine treatment of this trauma. The Plan 
denied your request. The Plan says there is no coverage for a limited oral evaluation. 
 
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 
limited oral evaluation provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visits provided from September 1, 2021, 
to September 28, 2021, by an OON provider. 
 
You asked the Plan to pay for the specialist office visits. You say that you are an in-network provider with the 
Plan, and you would like the claim to be paid. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 specialist office visits provided from 
September 1, 2021, to September 28, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a replacement cushion for use on nasal mask interface 
(A7032) provided on June 8, 2021. 
 
You asked the Plan to pay for a replacement nasal mask cushion. You say that the item at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have 
not been met.  
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies at issue in this case. The physician order in 
the case record does not address a replacement nasal mask cushion. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for a replacement cushion for use on nasal mask interface (A7032) provided on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on November 24, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the claim to be paid. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there was no referral from 
an in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
  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 an office visit provided on November 24, 2021, by 
an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation, both jaws, 
(D0367) provided on December 21, 2021. 
 
You asked the Plan to pay for the dental service. You say that you do not understand why this was completely 
denied. You say that the least the plan could do was pay for the type of x-ray that would be a covered service. 
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 Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the cone beam CT capture and 
interpretation is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the cone beam CT capture and interpretation, both jaws, (D0367) provided on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final 
restoration) (D3330) provided February 9, 2022. 
 
You asked the Plan to pay for the root canal. You say that you would like this service covered. 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 
endodontic therapy, molar tooth (excluding final restoration) (D3330) provided February 9, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has reduce the cost for the emergency room visit. 
 
You asked the Plan to waive the copayment for the emergency room visit . You say that feel you do not owe 
the copayment for outpatient hospitalization The Plan says that the $225 copayment applied correctly. 
 
We decided that the Plan has to reduce the copayment for the emergency room visit.  
 
The plan says you must pay $225 copayment for advanced imaging. The Plan has not forwarded any evidence 
or documentation to support advanced imaging was performed during the emergency room visit. It is the 
burden of the Health Plan to substantiate their decision with evidence. In this case, the decision to apply the 
advanced imaging copayment instead of the emergency care copayment has not been substantiated so we must 
find in your favor. Therefore, we decided that the Plan has to reduce the copayment for the emergency room 
visit from $225 to $90.  
 
We also decided that the Plan does not have to waive the copayment for the emergency room 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 $90 
copayment for an emergency room visit. Therefore, we decided that the Plan does not have to waive the 
copayment for the emergency room visit. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic testing provided on January 4, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the diagnostic testing. You say that it was medically necessary to provide the 
services to the enrollee and you would like the claim reprocessed for payment. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 diagnostic testing provided on January 4, 
2022, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Outpatient Upper GI Endoscopy on June 
21, 2021. 
 
You asked the Plan to waive the copayment for Outpatient Upper GI Endoscopy. You say that the services 
weren't rendered in an outpatient setting and you would like to appeal the cost share. The Plan denied your 
request. The Plan says the medical records were reviewed for this service and advised that the Upper GI 
Endoscopy was rendered in an Outpatient setting. 
 
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 $550 
copayment for Outpatient Upper GI Endoscopy.  
 
You have been asked to pay a $550 copayment for Outpatient Upper GI Endoscopy. Outpatient Upper GI 
Endoscopy falls within the Outpatient hospital 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 Outpatient Upper GI Endoscopy on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided from August 2, 2021, 
August 5, 2021, August 11, 2021, August 12, 2021, September 9, 2021, September 21, 2021, September 23, 
2021, September 28, 2021, October 7, 2021, October 11, 2021, October 13, 2021, and October 21, 2021, by an 
OON provider. 
 You asked the Plan to pay for the physical therapy services. You say that you were hurt while traveling and the 
physical therapy was a part of your treatment. The Plan denied your request. The Plan says the service rendered 
was outside of the Plan's service area and it was not considered an emergent or urgent needed service. 
 
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 physical therapy services provided from 
August 2, 2021, August 5, 2021, August 11, 2021, August 12, 2021, September 9, 2021, September 21, 2021, 
September 23, 2021, September 28, 2021, October 7, 2021, October 11, 2021, October 13, 2021, and October 
21, 2021, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81235, 81292, 81321, 81301) 
provided on August 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says these codes have not been billed 
appropriately based on Medicare coding regulations. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan
does not have to pay for the laboratory services (81206, 81235, 81292, 81321, 81301) provided on August 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on January 20, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are appealing the cost share 
applied. 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 $100 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service.  
 
You have been asked to pay a $100 copayment for an ultrasound. An ultrasound 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 an ultrasound provided on January 20, 2022.