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

 
We decided that the Plan does not have to pre-approve an osseous surgery (D4260) provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve an osseous surgery. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the requested dental 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 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 pre-approve an 
osseous surgery (D4260) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on July 18, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for injections. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
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 injections provided on July 18, 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 comprehensive periodontal evaluation (D0180) provided by 
an out-of-network provider on June 30, 2022. 
 
You asked the Plan to pay for comprehensive periodontal evaluation. You say that this provider was in-
network. The Plan denied your request. The Plan says the rendered dental 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 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 
comprehensive periodontal evaluation (D0180) provided by n out-of-network provider on June 30, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 24 physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that you want to continue physical therapy 
because it helps strengthen you and helps you with not losing your balance.  You say that you need help so that 
you will not lose the mobility you have now. The Plan denied your request. The Plan says an additional 24 
physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
   
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of additional physical therapy visits have 
been met. Specifically, medical records were not submitted to determine the medical necessity of additional 
visits. Therefore, we decided that the Plan does not have to pre-approve an additional 24 physical therapy 
visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) and the 
cone beam computed tomography (CT) image capture with limited field of view (D0380) provided on July 20, 
2022. 
 
You asked the Plan to pay 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 your benefit for the oral examination provided 
has already been exhausted. Additionally, the cone beam CT scan provided 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 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 oral examination was exhausted on date of service June 16, 2022. Specifically, the 
Plan provides coverage of two oral examinations per calendar year.  You previously received two oral examinations on May 26, 2022 and June 16, 2022, which were paid for by 
the Plan. Therefore, you have exhausted the allowable benefit for this service. Additionally, a cone beam CT 
scan is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation-problem focused (D0140) and the cone beam computed tomography (CT) image capture with 
limited field of view (D0380) provided on July 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that normal neurologists do not have experience 
with your condition. The Plan denied your request. The Plan says there are in-network providers that can 
provide this 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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
neurology services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for x-ray service provided on February 10, 
2022, to March 31, 2022. 
 
 
You asked the Plan to waive the deductible for x-ray service. You say that you disagree with the cost share. 
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 $450 
deductible for Section 1.2 What is your plan deductible? 
 
You have been asked to pay a $450 deductible for x-ray service. You are big asked to pay $108 towards your 
deductible. This item/service falls within the Section 1.2 What is your plan deductible? 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 deductible for x-ray service provided on February 10, 2022, to March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213), mechanical traction therapy (97012), 
and the electric stimulation therapy (97014) provided on July 1, 2022. 
 
You asked the Plan to pay 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 by the 
Plan or by Medicare. 
 
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 pay for the office visit (99213), mechanical traction therapy (97012), and the 
electric stimulation therapy (97014) provided on July 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for intraoral imaging (D0220) provided by an 
out-of-network provider on February 14, 2022. 
 
You asked the Plan to waive the coinsurance for intraoral imaging. You say that your normal doctor was on 
vacation. 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% 
coinsurance for dental services.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for intraoral imaging. The total allowed 
amount is $29. The total amount you are being asked to pay is $14.50 ($29 x 50% = $14.50). This item/service 
falls within the dental 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 coinsurance for intraoral 
imaging (D0220) provided by an out-of-network provider on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive orthodontic treatment (D8090) provided on 
February 9, 2022. 
 
You asked the Plan to pay for orthodontic treatment. You say that you disagree with the denial of orthodontic 
treatment. The Plan denied your request. The Plan says that comprehensive orthodontic treatment (D8090) is 
not covered by the enrollees dental 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 
comprehensive orthodontic treatment (D8090) provided on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 23, 2022. 
 
You asked the Plan to pay for an office visit. You say that authorization is usually not required. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on July 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health services provided to the enrollee from 
December 1, 2021, to December 31, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not reported correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
These home health services were not billed with any G or Q codes. Home health claims cannot be billed with 
only S codes. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the 
enrollee from December 1, 2021, to December 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Chiropractic visit provided on August 03, 2022. 
 
You asked the Plan to pay for a Chiropractic visit. You say that you confirmed you are considered in-network 
with the Plan but the claim as been denied due to being labeled as out-of-network. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a Chiropractic visit 
provided on August 03, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient surgery provided on April 27, 2022, to August 
05, 2022. 
 
You asked the Plan to pay for an outpatient surgery. You say that you were very sick and needed to find a 
surgeon to perform the procedure. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an outpatient surgery 
provided on April 27, 2022, to August 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim complete mandibular denture (D5811) provided 
on June 9, 2022. 
 
You asked the Plan to pay for an interim denture. You say that you disagree with the denial of the interim 
denture. The Plan denied your request. The Plan says an interim complete mandibular denture (D5811) is not 
covered by your dental 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 an interim 
complete mandibular denture (D5811) provided on June 9, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 76642 billed for date of service August 1, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim has been coded correctly. The Plan 
denied your request. The Plan says that code 76642 has an MUE value of 1. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
In this case, the CPT Code Manual definition of code 76642 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; limited. We find that CPT code 76642 has an MUE 
value of 2. The claim shows that 2 units of code 76642 was billed. CPT code 76642 was billed with 1 unit of 
service with modifier RT on one claim line, and 1 unit of service with modifier LT on the other claim line. 
Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we decided 
that the Plan has to pay for procedure code 76642 billed for date of service August 1, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient services on July 07, 2022. 
 
You asked the Plan to waive the copayment for outpatient services. You say that you want to appeal the 
amount being charged. 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 $350 
copayment for Medicare-covered surgery services at a hospital outpatient facility. Covered services include but 
are not limited to services in an emergency department or outpatient clinic, such as observation services or 
outpatient surgery.  
 
You have been asked to pay a $350 copayment for outpatient services. This item/service 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 
services on July 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for date of service 
June 1, 2022. 
 You asked the Plan to pay for procedure codes 88341 and 88342. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says payment for code 88341 
and 88342 is bundled into payment for code 88360. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
88341 and 88342 are both column II codes to column I code 88360. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 88341 and 88342 billed for 
date of service June 1, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 45378 billed for date of service March 29, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the diagnosis code is listed as medically 
necessary. The Plan denied your request. The Plan says the enrollee underwent a screening colonoscopy. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 45378 is colonoscopy, flexible; diagnostic, including 
collection of specimen(s) by brushing or washing, when performed (separate procedure). 
 
 
 We find that CPT code 45378 is not supported in the medical record. Specifically, the medical records do not 
show that specimens were collected. There is a more appropriate code available to describe screening 
colonoscopies. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 45378 billed 
for date of service March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
records do support a need for physical and occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.