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

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
January 19, 2022. 
 
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you were not aware of 
this copayment at the time of the visit, and therefore should not need to pay it. The Plan denied your request. 
The Plan says the copayment applied was 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 $30 
copayment for in-network telehealth services.  
 
You have been asked to pay a $30 copayment for a specialist telehealth visit. A specialist telehealth visit falls 
within the In-Network Telehealth Services - Virtual Specialist 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 a specialist telehealth visit provided on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services on February 26, 2022, to March 22, 2022. 
 
You asked the Plan to pay for prefabricated post and core (D2954) and an office visit for observation (D9430). 
You say that you would like to request reconsideration of the denied claim. The Plan denied your request. The 
Plan says these 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, 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 dental 
services on February 26, 2022, to March 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray exam provided on March 18, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an x-ray exam. You say that our physicians are hospital based. Our association 
has no opportunity to pre-authorize imaging studies. We rely on the hospital personnel to obtain all necessary 
paperwork including authorization numbers and referral forms. You say that you should not be penalized for 
actions (or lack of action) over which we have no control. 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 an x-ray exam provided on March 18, 2022, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 2, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no 
evidence to support the referring/ordering provider is/was treating the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  
 
We looked at the file and Medicare rules. The records provided do not show that the requested testing was 
ordered by the enrollee's treating physician. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pay for the lab services provided on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a chiropractor on March 18, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the office visit is not 
covered by the plan under any circumstance. The Plan also says chiropractic services are limited to three CPT 
codes, 98940 (chiropractic manipulative treatment; spinal, one to two regions), 98941 (three to four regions), 
and 98942 (five regions). 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided by a chiropractor on March 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of an upper 
extremity (73218). 
 
You asked the Plan to pre-approve an MRI. You say that an MRI is medically necessary. The Plan denied your 
request. The Plan says the criteria for coverage of an MRI are not met in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI. Our reviewer says that the 
requested MRI is not medically reasonable and necessary according to Medicare criteria. Our physician 
reviewer found that the enrollee presents with pain in the right arm with bruising and swelling following abrupt 
pulling large tractor tire chain. The enrollee had decreased strength and pain with movement. There is no 
deformity, mass, or signs of muscle detachment. X-rays did not show a fracture. An MRI is requested; 
however, there is insufficient support made in the provided records that would warrant an MRI at this time such 
as occult fracture, severe muscle or other soft tissue damage, or indication for surgery or other procedure that 
might warrant advanced imaging in this clinical situation. Therefore, this request for an MRI will be considered 
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 an MRI have not been met. Therefore, we decided that the Plan does not have to 
pre-approve magnetic resonance imaging (MRI) of an upper extremity (73218).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided on March 22, 
2022. 
 
You asked the Plan to pay for the partial denture. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says a maxillary partial denture (D5213) is not covered by your routine 
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 a 
maxillary partial denture (D5213) provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93355 billed for date of service February 2, 
2022. 
 
You asked the Plan to pay for procedure code 93355. The Plan denied your request. The Plan says payment for 
code 93355 is bundled into payment for code 00560.  
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 code 93355 
is a column II code to column I code 00560. 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 code 93355 billed for date of service February 2, 
2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay $30 more for the frames (V2020) and bifocal lens (V2200) provided on 
March 1, 2022. 
 
You asked the Plan to pay more for the frames and bifocal lens. You say that you were presented with a 
statement for $155.20 to be paid before you got the new glasses. You also say that you paid for it because you 
needed the glasses. The Plan denied your request. The Plan says that this claim was paid correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The record shows that the Plan paid $20 toward the glasses you 
purchased on March 1, 2022 from an in-network provider. The contract says that you have a $50 benefit to use 
toward glasses every year, and you are responsible for any amount over the $50 retail price. The documentation 
provided does not show that you had exhausted this benefit. The Plan contract also does not clearly state that 
the Plan will only pay up to the allowed amount if it is $50 or less for glasses. Based on this information, we 
decided that the Plan's rules for coverage of the frames and bifocal lens have been met. Therefore, we decided 
that the Plan has to pay $30 more for the frames (V2020) and bifocal lens (V2200) provided on March 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on October 13, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that the hospital these services were 
rendered at is in-network. You also say that it was filed wrong by the hospital, and they will not resubmit the 
claim. The Plan denied your request. The Plan says self-administered drugs are not covered under your medical 
plan.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on October 13, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) provided April 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that no one told you the provider was OON. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the crown - porcelain/ceramic (D2740) provided April 11, 2022, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology and laboratory procedures provided on March 23, 
2022, by an OON provider. 
 
You asked the Plan to pay for pathology and laboratory procedures. You say that you are appealing and request 
a reconsideration because 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 pathology and laboratory procedures provided on 
March 23, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction provided by a chiropractor on December 
7, 2021. 
 
You asked the Plan to pay for mechanical traction. You say that you have chiropractic benefits for 
manipulation of the spine. The Plan denied your request. The Plan says mechanical traction is not covered by 
the plan under any circumstance. 
 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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for mechanical traction provided by a chiropractor on December 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and panoramic x-
ray (D0330) provided on March 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 a comprehensive oral evaluation was exhausted on date of service July 14, 2021. The 
record also shows your benefit for a panoramic x-ray was exhausted on date of service December 14, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and 
panoramic x-ray (D0330) provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus and diphtheria toxoids (Tg) vaccine absorbed, 
preservative free, for use in individuals seven years or older, for intramuscular use (90714) Immunization 
administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial (90471) 
provided March 29, 2022. 
 
You asked the Plan to pay for the vaccination. You say that you are requesting reimbursement of the $75 fee 
that was rejected. You think a tetanus shot should be covered, but it is not. The Plan denied your request. The 
Plan says the diagnosis is not considered an appropriate diagnosis for a tetanus vaccine. The administration of a 
vaccine is not covered when the vaccine itself is not covered by the Plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccination. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccination. 
Therefore, we decided that the Plan does not have to pay for the tetanus and diphtheria toxoids (Tg) vaccine 
absorbed, preservative free, for use in individuals seven years or older, for intramuscular use (90714) Immunization administration for percutaneous, intra-dermal, subcutaneous or intramuscular injections, initial 
(90471) provided March 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service January 30, 
2022. 
 You asked the Plan to pay for procedure code 71045. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for 
code 71046. 
 
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 code 71045 
is a column II code to column I code 71046. 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 code 71045 billed for date of service January 30, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo. 
 
You asked the Plan to pre-approve Opdivo. You say that this is medically necessary. The Plan denied your 
request. The Plan says this use is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Opdivo. Our reviewer says that the 
requested use of Opdivo is not supported. Our physician reviewer found monotherapy with Opdivo with no 
prior chemotherapy is not Food and Drug Administration-approved or supported by one of the major drug 
compendia for the enrollees diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Opdivo.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a special anesthesia service provided on December 10, 2021, 
by an OON provider. 
 
You asked the Plan to pay for a special anesthesia service. You say that you are asking for a retro-authorization 
for claim due to the enrollee not being aware that a prior authorization was required for services to be rendered 
by an out-of-network provider. 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 special anesthesia service provided on December 
10, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), 
prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided February 3, 
2022. 
 
You asked the Plan to pay for the dental services. You say that services from this provider have been covered 
in the past and you were not told they would not be covered this year. The Plan denied your request. The Plan 
says the dental services were received from an out-of-network provider and are not covered by your 
supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), prophylaxis - adult (D1110) and periodic oral 
evaluation - established patient (D0120) provided February 3, 2022.  
 
Your complaint about coverage being provided in previous years is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service June 20, 
2021. 
 
You asked the Plan to pay for procedure code 71250. You say that this service was billed appropriately. The 
Plan denied your request. The Plan says payment for code 71250 is bundled into payment for code 71260. 
 
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 code 71250 
is a column II code to column I code 71260 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 code 71250 billed for date of service June 20, 2021.