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

 
We decided that the Plan does not have to waive the copayment for a telehealth visit provided on May 06, 
2022. 
 
You asked the Plan to waive the copayment for a telehealth visit. You say that this visit was due to covid, 
therefore, you thought there was no copayment. 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for a telehealth visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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. You have been asked to pay the allowed amount of 
$39, which is less than the $45 copayment for a telehealth visit. Therefore, we decided that the Plan does not 
have to waive the copayment for a telehealth visit provided on May 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92012 provided on August 15, 2022. 
 
You asked the Plan to pay for procedure code 92012. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise 
code that most fully explains the narrative description of the symptom or diagnosis. 
 
We looked at the file and Medicare rules. The file shows that procedure code 92012 was billed with one or 
more diagnosis codes that were inappropriately coded. Medicare rules say that some ICD-10-CM codes 
indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate 
to report left and right when a more specific bilateral diagnosis code is available. Therefore, we decided that 
the Plan does not have to pay for procedure code 92012 provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dentures (D5120) provided on July 7, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service 6/25/2021. Therefore, we 
decided that the Plan does not have to pay for dentures (D5120) provided on July 7, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft (D7953) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a bone replacement graft. You say that you would like the Plan to 
reconsider approval for these services. 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 a 
bone replacement graft (D7953) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3310) provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you really need these services provided. 
The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve endodontic 
therapy (D3310) provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for x-rays and podiatry services on August 15, 
2022. 
 
You asked the Plan to waive the copayments for x-rays and podiatry 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 $30 
copayment for each x-ray service. Covered services include but are not limited to x-rays. You must pay a $50 
copayment for each visit for podiatry services. Covered services include diagnosis and the medical or surgical 
treatment of injuries and diseases of the feet (such as hammer toe or heel spurs). $30 + $50 = $80. Therefore, 
results in the total cost sharing amount of $80.  
 
 You have been asked to pay a $30 copayment for x-rays and $50 copayment for podiatry services. This 
item/service falls within the Outpatient diagnostic tests and therapeutic services and supplies and Podiatry 
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 copayments for x-rays and podiatry 
services on August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management provided on August 23, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for principal care management. You say that you have no prior knowledge of the 
individuals you are required to see. The Plan denied your request. The Plan says there is no prior authorization 
on file for the services provided. 
 
 
 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 principal care management provided on August 
23, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services are for a follow up from a surgery. The 
Plan denied your request. The Plan says the referral was not authorized by the primary care physician. 
 
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 September 23, 2022, by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88112) provided on May 6, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with an outpatient 
hospital POS code. The records show that the enrollee was registered as inpatient from May 5, 2022, to May 
10, 2022. Therefore, we decided that the Plan does not have to pay for the laboratory services (88112) provided 
on May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7210 x32). 
 
You asked the Plan to pre-approve extractions. You say that the services are medically necessary. The Plan 
denied your request. The Plan says there is no physician order for these services. 
 
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 Medicare rules for 
coverage of extractions have not been met. At this time, sufficient information has not been submitted to 
support that coverage criteria for full mouth extractions have been met. Your dentist has recommended referral 
to an oral surgeon to evaluate whether extraction of two teeth is necessary. No order has yet been submitted by 
your dentist for any extractions, and you have not yet been seen by the oral surgeon. Without any provider 
documenting an intent to perform extractions, we cannot determine whether coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pre-approve extractions (D7210 x32).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a practitioner visit provided on July 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a practitioner visit. You say that you depend on the staff to verify eligibility and 
obtain proper authorization. The Plan denied your request. The Plan says there was no authorization on file for 
the services provided. 
 
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 practitioner visit provided on July 24, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection of sample for laboratory services provided on 
March 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for collection of sample for laboratory services. You say that the records attached 
support the services provided. The Plan denied your request. The Plan says there was no authorization obtained 
prior to 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 collection of sample for laboratory services 
provided on March 9, 2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 22, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that your provider ordered this and you 
should not have a copayment. 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 $115 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $108.68 which is less than the $115 copayment for an 
ultrasound. This item/service 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 
August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 9, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for practitioner services. You say that the services were provided medically 
necessary, and they were performed in good faith. The Plan denied your request. The Plan says there is no prior 
authorization on file for the services provided. 
 
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 practitioner services provided on August 9, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network outpatient diagnostic tests 
provided on July 27, 2022. 
 
You asked the Plan to waive the copayment for out-of-network outpatient diagnostic tests. You say that you 
disagree with the copayment. 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 out-of-network outpatient diagnostic tests.  
 
You have been asked to pay a 50% coinsurance for out-of-network outpatient diagnostic tests. The total 
allowed amount for the diagnostic test $66.34. You are being asked to pay $33.01 which is less than the 
required amount. This item/service falls within the out-of-network outpatient diagnostic tests 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 out-of-network outpatient diagnostic tests provided on July 
27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral  periapical first radiographic image (D0220) for 
tooth number 4, an intraoral  periapical each additional radiographic image (D0230) for teeth numbers 4 and 
5, a resin-based composite for two posterior surfaces (D2392) for tooth number 5, and a limited oral evaluation 
(D0140) for tooth number 4 provided from August 1, 2022, to September 22, 2022. 
 
  You asked the Plan to pay for an intraoral  periapical first radiographic image (D0220) for tooth number 4, an 
intraoral  periapical each additional radiographic image (D0230) for teeth numbers 4 and 5, a resin-based 
composite for two posterior surfaces (D2392) for tooth number 5, and a limited oral evaluation (D0140) for 
tooth number 4. You say that you received preventative dental services to remove an abscessed tooth. You also 
say that these procedures were vital to your health. The Plan denied your request. The Plan says the member 
already exhausted the benefit for an intraoral x-ray on February 16, 2022, and the resin-based composite  two 
surfaces posterior (D2392) on March 15, 2022. The Plan also says that there is no coverage for a limited oral 
evaluation (D0140). 
 
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, a limited oral evaluation (D0140) is 
not among those covered under this benefit. Also, though the Plan offers a dental benefit in excess of Medicare 
coverage, certain limitations apply. The record shows your benefit for an intraoral  periapical first 
radiographic image (D0220) for tooth number 4, and an intraoral  periapical each additional radiographic 
image (D0230) for teeth numbers 4 and 5 was exhausted on February 16, 2022. The record also shows that a 
resin-based composite for two posterior surfaces (D2392) for tooth number 5 was exhausted on date of service 
March 15, 2022. Therefore, we decided that the Plan does not have to pay for an intraoral  periapical first 
radiographic image (D0220) for tooth number 4, an intraoral  periapical each additional radiographic image 
(D0230) for teeth numbers 4 and 5, a resin-based composite for two posterior surfaces (D2392) for tooth 
number 5, and a limited oral evaluation (D0140) for tooth number 4 provided from August 1, 2022, to 
September 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that when the ambulance arrived you were 
thoroughly checked out to find the cause of the pain. You also say that the emergency medical services gave 
you the option to be transported to the emergency room by the ambulance or a neighbor and you chose your 
neighbor. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 31, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture and interpretation with field of view 
of both jaws; (D0367) provided on June 14, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation with field of view of both jaws; 
(D0367). You say that the x-ray billed was necessary to determine the size and location of the cyst. You also 
say that a regular x-ray cannot determine the information needed in this case. The Plan denied your request. 
The Plan says this service is not covered under the benefit package. 
 
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 cone 
beam CT capture and interpretation with field of view of both jaws; (D0367) provided on June 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the provision of inr test materials provided 
on July 28, 2021. 
 
You asked the Plan to waive the coinsurance for the provision of inr test materials. You say that you were not 
aware the provider was out-of-network. 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 50% 
coinsurance for diagnostic procedures and tests (out-of-network). 
 
You have been asked to pay 50% coinsurance for the provision of inr test materials. This item/service falls 
within the diagnostic procedures and tests (out-of-network) 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. The Medicare allowed amount for the test strips is 
$81.70, and the 50% coinsurance applied is $40.85. Therefore, we decided that the Plan does not have to waive 
the coinsurance for the provision of inr test materials provided on July 28, 2021.