Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on June 29, 2022 
to July 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you thought the services would 
be covered by the Plan. The Plan denied your request. The Plan says provider is out of network and there is no 
referral on file. 
 
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 outpatient mental health services provided on June 
29, 2022 to July 26, 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 an amalgam filling on tooth #17 (D2150) and a resin-based 
composite on tooth #8 (D2330) provided on September 13, 2022. 
 
You asked the Plan to pay for the fillings. You say that the provider should have waited until next year to do 
the other two fillings. 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 the requested items or services was exhausted on date of service February 9, 2022. 
Therefore, we decided that the Plan does not have to pay for an amalgam filling on tooth #17 (D2150) and a 
resin-based composite on tooth #8 (D2330) provided on September 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on July 11, 2022. 
 
You asked the Plan to pay for a home health visit. You say that you are requesting reconsideration for the 
denied claim stating medical records are provided to prove medical necessity. 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 home health visit 
provided on July 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service May 22, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says procedure code 99053 is considered 
bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service May 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent urinary catheter supplies provided on April 28, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for intermittent urinary catheter supplies. You say that the supplies were covered in 
the past. The Plan denied your request. The Plan says the services are not a covered benefit and there is no prior 
authorization on file. 
 
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 intermittent urinary catheter supplies provided on 
April 28, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan 
provided on August 10, 2022. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan. You say that you went to 
emergency the week before and you feel this bill is too much. 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 $325 
copayment for diagnostic radiology services that are not ultrasounds. 
 
You have been asked to pay a $325 copayment for the computed tomography (CT) scan. This item/service falls 
within the diagnostic radiology services that are not ultrasounds benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the computed tomography (CT) scan provided on August 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on July 20, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you shouldnt have to pay for this. 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for ER visit. This item/service falls within the Emergency care 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.You 
have been asked to pay $67.77 which is less than the standard $90 copayment for an ER visit. Therefore, we 
decided that the Plan does not have to waive the copayment for ER visit provided on July 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
December 10, 2021, to January 11, 2022. 
 
You asked the Plan to pay for the services. You say that there is supporting documentation for reconsideration 
of payment. The Plan denied your request. The Plan says the provider did not send in an itemized bill, after 
many attempts. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the services have been met. Despite multiple requests by the plan, an itemized bill was not sent in the by the provider. This is needed for this sort of 
case. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the 
enrollee from December 10, 2021, to January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous Electrical Nerve Stimulation (PENS). 
 
You asked the Plan to pre-approve PENS. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that peripheral nerve stimulators are covered when 
specific criteria are met. 
 
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 PENS. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found this is considered an 
experimental/investigational procedure. Therefore, the request is deemed not medically reasonable or 
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 PENS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Percutaneous Electrical Nerve Stimulation (PENS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) 
provided on July 20, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not payable as it was not 
rendered by an oral surgeon. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers this service 
when rendered only by an oral surgeon.  
 
We looked at the case file and the Plans rules. Based on this information, we decided that the Plan's rules for 
coverage of this service have not been met. Specifically, the Plans contract states that a limited oral evaluation 
is only covered when rendered by an oral surgeon. The limited oral evaluation in this case was rendered by a 
dentist, who is not an oral surgeon. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation-problem focused (D0140) provided on July 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a complete mandibular denture (D5120) and does not 
have to pay for an unspecified diagnostic procedure (D0999) provided on February 8, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were given incorrect information 
about the provider being in-network. The Plan denied your request. The Plan says the enrollee is responsible 
for any charged amount above the Plans cost-sharing amount when your services are received from an out-of-
network provider. The Plan also says that an unspecified diagnostic procedure (D0999) is not covered by the 
enrollee's 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for a complete mandibular denture (D5120). This cost sharing is a contractual obligation you agreed 
to pay when you enrolled in the Plan. Though the Plan offers a dental benefit in excess of Medicare coverage, an unspecified diagnostic procedure 
(D0999) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay more for a complete mandibular denture (D5120) and does not have to pay for an unspecified diagnostic 
procedure (D0999) provided on February 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission and left atrial appendage closure 
(LAAC). 
 You asked the Plan to pre-approve inpatient admission and LAAC. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that LAAC devices are covered when specific criteria are 
met. 
 
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 inpatient admission and LAAC. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found there is no apparent 
contraindication to anticoagulation. As such, guidelines would not support implantation of a LAAC in this 
setting. In summary, LAAC placement would not be considered reasonable or medically necessary in this 
enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission and LAAC have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient admission and left atrial appendage closure (LAAC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for prophylaxis (D1110) provided on May 24, 2022. 
 
You asked the Plan to pay more for prophylaxis. You say that you are asking for reimbursement for the dental 
cleaning. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for prophylaxis. 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 pay more for prophylaxis (D1110) provided on 
May 24, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 8, 2022, to 
February 6, 2022. 
 
You asked the Plan to pay for the home health services. 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. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Medicare rules say for all enrollees receiving 
home health services in 2021 whose services will continue in 2022, the home health agency shall submit an 
NOA with a one-time artificial admission date corresponding to the From date of the first period of 
continuing care in 2022. Based on this information, we decided that Medicare rules for completing the claim 
for home health services have not been met. Specifically, the file shows that the final claim was submitted with 
an admission date of November 9, 2021, and not the admission date reported on the NOA. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 8, 2022, to 
February 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided on September 05, 2022. 
 
You asked the Plan to pay for acupuncture services. You say that you are requesting reconsideration for the 
denied claim because you were under the impression the Plan covers acupuncture for back pain. 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 acupuncture services 
provided on September 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), periapical x-rays 
(D0220, D0230), and bitewing x-rays (D0274) provided on October 18, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had to seek a new dentist because your 
previous dentist stopped taking your insurance. 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 February 12, 2019. 
The record also shows your benefit for periapical x-rays and bitewing x-rays was exhausted on date of service 
March 18, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150), periapical x-rays (D0220, D0230), and bitewing x-rays (D0274) provided on October 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on July 
21, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you shouldnt have to 
pay for this. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B drugs. This item/service falls within the 
Medicare Part B prescription drugs 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 
Medicare Part B drugs provided on July 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 20, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service February 20, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on  
June 30, 2022. 
 
You asked the Plan to pay for this dental service. 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 service provided 
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 service provided was exhausted on date of service October 20, 2021. Specifically, 
the Plans contract states that a comprehensive oral evaluation is covered once every 36 months. You 
previously received this service on October 20, 2021, which was paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for 
the comprehensive oral evaluation (D0150) provided on June 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy provided on May 
13, 2022. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that you shouldnt have to 
pay for this this should have been a routine colonoscopy. 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 $200 
copayment for Outpatient surgery. 
 
You have been asked to pay a $200 copayment for diagnostic colonoscopy. This item/service falls within the 
Outpatient surgery 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 diagnostic 
colonoscopy provided on May 13, 2022.